Psych CASC / OSCE · General adult psychiatry — impulse control
Explain kleptomania and treatment options — CASC communication station
MRCPsych/FRANZCP-style communication station: explain kleptomania without pejorative labels, outline CBT and off-label naltrexone honestly, address shame and suicide risk, confidentiality limits, check understanding.
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Target exams
Station brief
Format. Communication station, approximately 7–10 minutes active time after reading. You are the psychiatry registrar in the outpatient clinic. [2]
Candidate instructions. Explain kleptomania in clear non-stigmatising language, separate it from “career criminal,” outline psychological and medication options with honest evidence limits (including that naltrexone is not a drug-of-abuse treatment label in this context but an off-label opioid antagonist studied for urges), address risk and court-report honesty, assess despair/suicide risk sensitively, and check understanding. The examiner plays the patient. [1][3]
Candidate scenario
Your patient has recurrent stealing of unneeded items with tension-relief phenomenology, repeated arrests, shame, and no clear manic syndrome. She is ambivalent about treatment and fearful of stigma. She is not psychotic. Alcohol use is light–moderate. No current fire-setting risk. [2][3]
Marking domains
- Empathy and structure without colluding with minimisation or shame spirals
- Accurate plain-language explanation of kleptomania (unneeded objects; urge–relief cycle)
- Honest treatment discussion (CBT skills; naltrexone evidence; not a miracle pill; LFT/opioid safety)
- Risk, court honesty, confidentiality limits when others are harmed
- Suicide risk enquiry after arrests
- Teach-back and follow-up plan [1][3]
Reveal assessor key
Open and agenda-set. Name time; acknowledge stigma and fear about labels and court; ask what she has already been told. [2]
Explain diagnosis. “Kleptomania describes repeated stealing of things you do not actually need for use or money, driven by a rising urge and short relief, often followed by guilt. It is a clinical impulse-control diagnosis, not a moral insult and not the same as saying someone is a professional thief. We still take legal responsibility seriously.” [2][3]
Explain treatment. Skills-based therapy helps map triggers, ride out urges, change justifications, and plan safer responses. Medicines do not magically erase responsibility. An oral medicine called naltrexone has trial evidence reducing urges and stealing compared with placebo; we would check liver blood tests, make sure you are not on opioids, start around 50 mg daily by mouth if appropriate, and review carefully — this is off-label and not a claim that you have an opioid addiction. Antidepressants may help if depression is present but are not a proven stand-alone cure for the stealing drive. [1][3][4]
Risk and court. We assess despair and suicide risk after arrests because shame can become dangerous. Reports to court should be honest about diagnosis, uncertainty, and what treatment can and cannot guarantee. Privacy has limits if there is serious risk to others. [2]
Close. Agree goals (urge diary, CBT referral, consider naltrexone after labs, early review), teach-back, written information, hope without false promises. [1][3]
Examiner pitfalls to watch
- Collapsing kleptomania into “career criminal” or refusing all treatment
- Overpromising cure with medication alone
- Ignoring post-arrest suicide risk
- Using jargon without checking understanding
- Failing to explain LFT/opioid safety for naltrexone
References
- [1]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.PMID 19217077
- [2]McElroy SL, Pope HG Jr, Hudson JI, et al. Kleptomania: a report of 20 cases Am J Psychiatry, 1991.PMID 2018170
- [3]Schreiber L, Odlaug BL, Grant JE Impulse control disorders: updated review of clinical characteristics and pharmacological management Front Psychiatry, 2011.PMID 21556272
- [4]Koran LM, Aboujaoude EN, Gamel NN Escitalopram treatment of kleptomania: an open-label trial followed by double-blind discontinuation J Clin Psychiatry, 2007.PMID 17388713