Kleptomania and pyromania — retail arrest and arson differential (MEQ)

(i) Working diagnosis and differentials. Working diagnosis: kleptomania (DSM-5-TR) — recurrent failure to resist stealing objects not needed for use or monetary value; tension before and pleasure/relief at theft; not anger/vengeance or delusion-driven; not better explained by CD, mania, or ASPD on the information given; distress, legal consequences, and repeated arrests support clinical significance. Collateral and full mood/SUD history still required.^[3][6]

Differentials with discriminators: (1) Instrumental theft — need or profit motive and use of goods for value; here items are unneeded. (2) Manic/mixed episode — multi-domain disinhibition with decreased need for sleep and other manic features lasting days–weeks; denied here but must be excluded carefully. (3) Substance-induced — acts only when intoxicated; she reports sober episodes. (4) ASPD/CD pattern — pervasive rights violation and conduct history; not described as primary longitudinal pattern. Also keep OCD-spectrum and depression-with-secondary-behaviour on the formulation list.^[3][6]

(ii) Medium-term treatment. Psychological: CBT with stimulus control (shopping plans, accompaniment, high-risk cue avoidance), urge surfing, cognitive restructuring of justifications, response prevention alternatives, relapse prevention, and motivational work around shame without collusion. Track urge diaries and legal liaison as needed.^[6] Pharmacological: Off-label naltrexone has double-blind RCT support versus placebo for reducing stealing urges and behaviour. Practical plan: baseline LFTs, exclude current opioid use, counsel off-label status and hepatotoxicity risk; start naltrexone 50 mg orally daily, review urges/behaviour/adherence and interval LFTs, continue only with benefit alongside CBT. Do not overclaim SSRIs: escitalopram open-label signal then failed double-blind discontinuation maintenance.^[1][4][6] Assess suicide risk after arrests; treat comorbid depression/SUD.

(iii) Pyromania and arson risk. Fire 1 (revenge after neighbour argument) fails pyromania because fire-setting to express anger/vengeance is an exclusion. Fire 2 during intoxication fails because impaired judgment/substance-related setting and absence of fascination/tension-relief primary motive argument against pyromania. Fire-setting is behaviour; arson is the charge; pyromania is rare.^[2][5] Priorities: multi-agency risk (police/probation, fire service, mental health), secure accelerants/access, treat substance use, structured suicide assessment if shame/legal crisis, collateral, capacity for justice process, honest court language about base rates, and behavioural safety planning — not a labelled anti-fire drug as primary care.^[2][5]