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Stealing behavior in eating disorders: Characteristics and associated psychopathology
Stealing Behavior in Eating Disorders: Characteristics and Associated Psychopathology Walter Vandereycken and Veerle Van Houdenhove The objective of the study was to identify, in detail, the characteristics of stealing behavior and eventual associated psychopathology in a large group of eatingdisordered patients. A sample of 155 females meeting DSM-III-R criteria for anorexia nervosa (AN) or bulimia nervosa BN completed the Stealing Behavior Questionnaire (SBQ) and other self-reporting measures, including the Dissociation Questionnaire (DIS.Q). In a subgroup of 80 patients, the SBQ was repeated after 2 months' treatment. A total of 47.1% of the patients admitted a history of stealing; compared with restricting AN (35.3%), the proportion of stealers was higher in binge-eating/purging AN (54.8%) and BN (48.7%). The number of patients admitting to stealing did not change after 2 months of intensive treatment. Com-
pared with other patients, stealers did not differ in signs of general psychopathology, but showed more abnormal scores on the DIS-Q (especially "loss of control"). The patients whose stealing was clearly related to their eating disorder did not show a distinct pattern of eating pathology or associated psychopathology. If studied in a systematic way, stealing appears to be more frequent than expected; with its relationship to bulimic tendencies and "loss of control," it might indicate a more severe (stage of an) eating disorder and, as such, deserves more attention from researchers and clinicians than the scarce literature is reflecting up to now.
N A N O R E X I A NERVOSA (AN) patients,
two major aims. Our first aim was to investigate in a systematic way the occurrence of stealing behavior in a large group of eating disorder patients. We assumed that it would be more frequent in patients who suffer from bingeeating. We also supposed that, at first assessment, patients might show a tendency to deny this behavior--especially anorectics9--and that they would be more willing to admit it after a period of treatment. Our second aim was to find various patterns of stealing behavior. We assumed that in some patients it was a wellplanned action to get food (or money to buy it), while in others it would instead have the characteristics of an impulse dyscontrol and/or show dissociative features, as in kleptomania. 1°
I stealing behavior was first connected with the sometimes strange habit of hoarding foods or objects and, as such, it was considered a form of kleptomania for which patients should be treated, not punished. 1 The association of stealing and anorectic behavior even in non-Western countries has stimulated various interpretations, ranging from biological to psychodynamic views. 2 In early reports on bulimia, a connection was made between compulsive eating and stealing. 3 Soon after the official nosographic recognition of bulimia in DSM-III, several reports made mention of stealing behavior as an aspect of "impulsivity" in these patients. 4,5 And from the opposite viewpoint, in recent years studies on kleptomania paid attention to its frequent connection with eating disorders. 6 Finally, stealing has been related to the new phenomenon of "compulsive buying"; a lifetime diagnosis of an eating disorder was found in 17% 7 to 20.8% 8 of these subjects. Inspired by these various reports, we wanted to pay more specific attention to this issue, but we soon realized that the research literature showed serious shortcomings. Therefore, we planned the present study with From the Department of Clinical Psychology, Catholic University of Leuven, Leuven, Belgium. Address reprint requests to Walter Vandereycken, M.D., Ph.D., Liefdestraat 10, 3300 Tienen, Belgium. Copyright © 1996 by W.B. Saunders Company 0010-440)(/96/3705-0001503. 00/0 316
Copyright © 1996 by W.B. Saunders Company
METHOD
Subjects One hundred fifty-five females meeting DSM-III-R criteria for eating disorders (the only selection criterion) were recruited from three different treatment settings: 65 had been admitted to a specialized eating disorders unit of a university hospital, 56 were inpatients at a behavior therapy unit of a general psychiatric hospital known for treating eating disorders, and 34 were outpatients from a private practice of a clinical psychologist specializing in the treatment of eating disorders. The cases of AN were subdivided (in accordance with DSM-IV subtyping) into a "restricting" type or pure fasters (n = 51), and a "mixed" type with binge-eating and/or vomiting/purging (n = 62). Of the 39 bulimia nervosa (BN) patients, 10 were at least 15% overweight. Three patients were diagnosed as "eating disorder not otherwise specified" (NOS). 11 Except for obvious features (such as weight and eating behavior), there were no significant differences between restricting AN, mixed AN,
ComprehensivePsychiatry, VoI. 37, No. 5 (September/October), 1996: pp 316-321
STEALING BEHAVIOR IN EATING DISORDERS
and BN with respect to age (mean_ SD, 23.5 _+ 7.3 v 22.5 -+ 5.7 v 23.0 ± 3.8 years, respectively) or duration of illness (5.9 ___5.4 v 4.7 --_3.5 v 5.3 ± 3.2 years). Although applied in different settings, the basic ideas of the multidimensional therapy were the same for all patients; all therapists were trained and supervised by one of us (W.V.).11
Procedure All data were gathered and analyzed by a female researcher (V.V.H.), who was not involved in the treatment. Confidentiality of the results was guaranteed to all patients. (It was explicitly stated that their therapists would not be informed.) At first assessment, before starting treatment, all patients were asked to complete a series of self-reporting questionnaires. The first set of validated questionnaires was aimed at assessing features directly related to the eating disorder itself. The Eating Disorder Evaluation Scale (EDES) 12is an easy and comprehensive self-reporting instrument for the clinical judgment of the severity of eating disorders containing four subscales: anorectic preoccupation, bulimic behavior, sexuality, and psychosocial adjustment. The Body Attitude Test (BAT) 13 is a self-reporting questionnaire developed for female patients suffering from eating disorders. It measures three aspects of body experience: negative appreciation of body size, lack of familiarity with one's own body, and general body dissatisfaction. The second set of self-reporting instruments was chosen to assess psychopathology in general and specific comorbidity in particular. The Symptom Checklist (SCL-90) 14 is a well-known measure for the assessment of a wide array of psychiatric symptoms (e.g., anxiety, depression, somatization, sensitivity, and hostility). Another "classic" instrument is the Beck Depression Inventory (BDI), 15which measures the degree of depression. The Dissociation Questionnaire (DIS-Q) 16 is aimed at assessing dissociative experiences: identity confusion and fragmentation (referring to experiences of depersonalization and derealization), loss of control (over one's behavior, thoughts, and emotions), amnesia (memory lacunas), and absorption. Finally, for the purpose of this study we developed an exploratory instrument--the Stealing Behavior Questionnaire (SBQ). The subject is first asked whether he/she has ever stolen anything. In the introduction, it is stated: "With stealing we mean taking without permission any object, regardless of its value, that doesn't belong to you. If this happened at your (family's) home it should also be considered as stealing, except for foods and drinks." If the subject answered "no," he/she was then asked: "Have you ever felt the urge to steal, without doing it?" The type and content of the other questions is described in The Results section. A group of 80 patients was asked to complete the SBQ a second :time after about 2 months (the period during which all were either in inpatient treatment or weekly outpatient psychotherapy). RESULTS
First Versus Second Assessment In a first step, we c o m p a r e d the results on the S B Q at first a s s e s s m e n t a n d a f t e r 2 m o n t h s '
317
t r e a t m e n t (n = 80). Surprisingly, t h e r e w e r e a l m o s t no d i f f e r e n c e s in t h e a d m i t t a n c e o f stealing: t h r e e p a t i e n t s c h a n g e d t h e i r a n s w e r from " y e s " to " n o , " a n d two p a t i e n t s d i d the o p p o s i t e . Also, with r e g a r d to m o r e c o n c r e t e facts o f stealing (e.g., frequency, places, ages, a n d objects), p r a c t i c a l l y no m e a n i n g f u l c h a n g e s in answers w e r e found. Twelve p a t i e n t s ( 1 5 % ) a d m i t t e d at s e c o n d a s s e s s m e n t a g r e a t e r freq u e n c y of stealing d u r i n g t h e p a s t year; this could b e i n t e r p r e t e d as a sign of g r e a t e r h o n e s t y a n d / o r m o r e stealing in the p e r i o d since t h e first a s s e s s m e n t (the S B Q now c o v e r e d t h e s e 2 treatment months). On the question of whether they h a d t a l k e d with s o m e o n e a b o u t t h e i r stealing, 10 (12.5%) p a t i e n t s c h a n g e d t h e i r a n s w e r f r o m " n o " to " y e s , " a n d 16 ( 2 0 % ) now i n c l u d e d a t h e r a p i s t in t h e list o f p e r s o n s with w h o m t h e y h a d s p o k e n a b o u t it. W i t h r e s p e c t to q u e s t i o n s r e l a t e d to feelings a n d t h o u g h t s a b o u t t h e stealing, 25% o f t h e p a t i e n t s a n s w e r e d differently t h e s e c o n d time, showing m o r e "psychological insight."
Characteristics of Stealers S e v e n t y - t h r e e p a t i e n t s (47.1%) a d m i t t e d to having stolen (we will r e f e r to t h e m as " s t e a l ers"), i n c l u d i n g 35.3% o f restricting A N , 54.8% of m i x e d A N , a n d 48.7% o f B N p a t i e n t s . O n l y t h e difference b e t w e e n r e s t r i c t i n g a n d m i x e d A N r e a c h e d statistical significance (P < .05). T h e r e was no significant d i f f e r e n c e with r e s p e c t to the clinical setting. O f t h e p a t i e n t s who r e p o r t e d n e v e r to have stolen, 8.5% a d m i t t e d t h e y o n c e h a d t h e urge to do it. C o m p a r e d with the o t h e r p a t i e n t s , t h e s t e a l e r s d i d n o t differ in age, b u t t h e i r m e a n d u r a t i o n o f illness was g r e a t e r (5.8 --- 4.1 v 4.3 _+ 4.2 years, P < .05) a n d a s m a l l e r p r o p o r t i o n was m a r r i e d (9.9% v 1 6 . 7 % , P < .01). On the self-reporting questionnaires related to a s p e c t s o f the e a t i n g d i s o r d e r ( E D E S a n d B A T ) , no significant differences w e r e found, with o n e i m p o r t a n t e x c e p t i o n : on the b u l i m i a subscale o f the E D E S , the stealers s c o r e d significantly (P < .0001) lower (i.e., m o r e a b n o r m a l ) t h a n the o t h e r s (9.8 + 5.0 v 13.4 -+ 5.2). W i t h r e g a r d to various p s y c h o p a t h o l o g i c a l c o m p l a i n t s (SCL-90) o r d e p r e s s i o n ( B D I ) , no significant differences w e r e found. H o w e v e r , the stealers showed more pronounced features
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VANDEREYCKEN AND VAN HOUDENHOVE
of dissociative experiences and behaviors, with the most distinct difference on the DIS-Q "loss of control" subscale (Table 1).
Aspects of Stealing Details about the stealing behavior are summarized in Table 2. In about 45% of the cases, stealing started before the eating disorder, and in more than half of the patients it occurred more than once during the past year. It mostly concerned food and/or money, and most often occurred at home or in a shop. About 40% of the stealers have been caught at least once, and for half of them this happened in a shop or supermarket (one third were fined). In about one third, the stolen object was not the main motive, but rather the act of stealing itself had a special meaning.
Types of Stealers Combining three questions--stolen object, motive for stealing, and patient's idea about relationship to AN/BN--two independent assessors reached a correspondence of 93.2% in subdividing the sample according to whether the stealing was related (group A, 62.5%) versus unrelated (group B, 37.5%) to an eating disorder. (One case was dropped for lack of important information.) Except for the aspects directly related to the subgrouping, in most group A cases stealing still occurred during the past year and in a marked frequency. They also stole more from friends, felt less guilty before but more excited or confused during stealing, and only half of them were convinced that stealing would not occur again. With respect to age, marital status, duration of illness, body mass index, and treatment setting, no significant differences were shown between group A and B. The same applied to the scores on all questionnaires (EDES, BAT, SCL-90, DIS-Q, and BDI). Table 1. Scores on the DIS-Q Mean +_SD DIS-Q Scale
Stealers(n = 73)
Nonstealers(n = 82)
P .0020
Total
2.29 _+ 0.63
1.87 -+ 0,43
Confusion
2.37 _+ 0.78
1.89 _+ 0,59
.0007
Loss of control Amnesia Absorption
2.52 -+ 0.77
2.00 +- 0.54
.0002
1.65 --. 0.58
1.37 -+ 0,33
.0034
2.69 -+ 0.74
2.46 -+ 0.71
.0111
DISCUSSION
A self-report study in eating disorder patients has always to face the bias of expectancy ("social desirability") and the problem of denial, especially in AN patients. 9 One might expect that such a distortion of answering patterns a fortiori would take place when patients are questioned about a socially unacceptable behavior such as stealing. We supposed that some eating disorder patients would first need to build up a trustful therapeutic relationship and/or gain some psychological insight before being ready to reveal information which would bring them in a vulnerable position. However, at second assessment--after 2 months' intensive treatment--virtually the same number of patients admitted stealing. On the other hand, changes in the content of some answers may be influenced by the ongoing treatment, which elicits a greater openness, and different feelings and thoughts about stealing and its significance. The limited influence of therapy on answers to the SBQ might be related to the selection of our sample: the majority of patients had been in treatment elsewhere and were ready now to engage in a specialized and demanding treatment. Hence, our patients might have shown a more than average willingness (and "psychological insight") to reveal delicate information about themselves. Differences between this and other studies may also be due to the definition of stealing and the assessment method. (We preferred an anonymous questionnaire instead of the more "embarrassing" confrontation with an interviewer.) Another stumbling block in comparing data is the diagnostic criteria used. Even if we only look at studies in which at least DSM-III-R criteria have been used (as the definition of bulimia in DSM-III was too broad), there remains the problem of subdividing AN. The problem with most preDSM-IV studies is that if they speak about "mixed" AN they refer to binge-eating anorectics and thus include the nonbulimic purging anorectics within the "restricting" type. Garner et al. 17 have clearly demonstrated that purging behavior (i.e., self-induced vomiting and/or laxative abuse) is an important distinguishing characteristic regardless of whether or not AN anorectics report binge-eating. Although details are lacking, these authors re-
STEALING BEHAVIOR IN EATING DISORDERS
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Table 2. Aspects of Stealing (Cont'd)
Table 2. Aspects of Stealing Total Question/Response
No.
(%)
Group A No.
(%)
Total
Group B No.
(%)
P*
First time, how long ago? <5yr 5tol0yr >10yr Last time, how long ago? <4mo 4tol0mo >10mo Total number of times Once 2 t o 5times >5times Frequency in past year None 1 to l 0 t i m e s >Onceamonth >Onceaweek Goods stolent Food items Money Toilet items, clothes Others Use of stolen goods1" Used it Kept without use Given away or restored Thrown away Where or from whom?? Parents, siblings Other family or friends Shop or supermarket School or w o r k site Others Did you plan it? Notatall Moreorless Well planned Feelings just beforet Tense Anxious Guilty Depressed Others* Feelings during stealingt Tense Anxious Guilty Depressed Others*
n 29 20 24
=73 n=45 n=27 (39.7) 20 (44.4) 9 (33.3) (27.4) 12 (26.7) 7 (25.9) (32.9) 13 (28.9) 11 (40.8)
n = 66 28 (42.4) 7 (10.6) 31 (47.0) n=73 14 (19.2) 24 (32.9) 35 (47.9)
n = 40 n = 25 <.001 22 (55.0) 6 (24.0) 7 (17.5) 0 - 11 (27.5) 19 (76.0) n=45 n=27 <.001 0 -13 (48.2) 17 (37.8) 7 (25.9) 28 (62.2) 7 (25.9)
n 33 25 7 8 n 44 23 17 24 n 62 12
n 12 18 7 8 n 36 14 9 15 n 42 9
= 73 (45.2) (34.2) (9.6) (11.0) = 68 (64.7) (33.8) (25.0) (35.3) = 71 (87.3) (16.9)
11 (15.5) 5 (7.0)
= 45 n = 27 <.001 (26.7) 20 (74.1) (40.0) 7 (25.9) (15.5) 0 - (17.8) 0 - = 45 n = 22 (80.0) 7 (31.8) <,001 (31.1) 9 (40.9) (20.0) 8 (36.4) (33.3) 9 (40.9) = 45 n = 25 (93.3) 19 (76.0) <,05 (20.0) 3 (12.0)
6 (13.3) 4 (8.9)
5 (20.0) 1 (4.0)
n = 72 n = 45 n = 26 28 (40.0) 18 (40.0) 11 (42.3) 22 (31.4) 18 (40.0) 31 13 9 n 45 21 4 n 38 30 12 12 24
(44.3) (18.6) (12.9) = 70 (64.3) (30.0) (5.7) = 58 (65.5) (51.7) (20.7) (20.7) (41.4)
n=68 49 (72.1) 45 (66.2) 19 (27.9) 5 (7.4) 25 (36.8)
17 10 8 n 26 16 3 n 25 22 5 9 18
4 (15.4) <.005
(37.8) 14 (53.8) (22.2) 3 (11.5) (17.8) 1 (3.8) = 45 n = 24 (57.8) 18 (75.0) (35.5) 5 (20.8) (6.7) 1 (4.2) = 40 n = 17 (62.5) 13 (76.5) (55.0) 8 (47.1) (12.5) 7 (41.2) <.001 (22.5) 3 (17.6) (45.0) 6 (35.3)
n=45 n =22 36 (80.0) 12 (54.5) <.001 27 (60.0) 17 (77.3) 11 (24.4) 8 (36.4) 3 (6.7) 2 (9.1) 21 (46.7) 4 (18.2) <.001
Group A
Question/Response
No.
(%)
No.
Feelings afterwardst Tense Anxious Guilty Depressed Others:l: Have you ever been caught? Never Yes, at least once Yes, more than once To w h o m did you reveal it? Noone Family member Spouse or boyfriend Friend Therapist Stealing in the future§ Neveragain Very unlikely Might happen again Don't k n o w Reason for stealingt Togetfood Lack of money Anger or revenge For fun or sensation Uncontrollable urge Related to eating disorders?ll Notatall Possibly Certainly No idea
n 26 37 60 21 26
= 68 (38.2) (54.4) (88.2) (30.9) (38.2)
n 17 25 38 15 19
(%)
Group B No.
(%)
P*
= 44 n = 23 (38.6) 8 (34.8) (56.8) 12 (52.2) (86.4) 21 (91.5) (34.1) 6 (26.1) (43.2) 7 (30.4)
n = 73 n = 45 n = 27 44 (60.3) 24 (53.3) 19 (70.4) 29 (39.7) 21 (46.7) 8 (29.6) 12 (16.4)
9 (20.0)
3 (11.1)
n = 72 n = 45 n = 26 26 (36.1) 14 (31.1) 12 (46.1) 25 (34.7) 19 (42,2) 6 (23.1) 11 25 16 n 28 17 14 14 n 27 19 14 11 9
(15.3) (34.7) (22.2) = 73 (38.4) (23.3) (19.2) (19.2) = 70 (38.6) (27.1) (20.0) (15.7) (12.9)
6 14 14 n 10 11 12 12 n 24 13 9 4 9
(13,3) 5 (19.2) (31,1) 10 (38.5) (31.1) 2 (7.7) = 45 n = 27 <.01 (22.2) 17 (63.0) (24.4) 6 (22.2) (26.7) 2 (7.4) (26.7) 2 (7.4) = 45 n = 24 (53.3) 3 (12.5) <,001 (28.9) 6 (25.0) (20.0) 5 (20.8) (8.9) 6 (25.0) (20.0) 0 - <.05
n 20 15 33 3
= 71 n = 45 n = 25 <.001 (28.2) 5 (11.1) 14 (56.0) (21.1) 10 (22.2) 5 (20.0) (46.5) 28 (62.2) 5 (20.0) (4.2) 2 (4.5) 1 (4.0)
NOTE. Group A, stealing related to eating disorder; group B, other form of stealing. *A v B, X2 test. Percentages refer to the group of stealers only. t O n these questions, the patient could mark more than 1 possibility. t o t h e r feelings included excited, confused, or ashamed. §Do you think that, in the future, stealing could happen to you again? IIDo you think that stealing (or the urge to do it) has something to do with having an eating disorder?
ported the following figures on "history of stealing" in AN subgroups (data on a large sample of patients attending a specialized treatment program): 2% in nonpurging restricters, 7% in purging restricters, and 17% in bulimic anorectics. 17 If we take DSM-III-R criteria as basis for a
320
comparison, only a few studies have systematically examined stealing behavior in eating disorders. Current and lifetime psychiatric diagnoses in 229 female patients seeking treatment for an eating disorder have been studied by Herzog et al. 18 Kleptomania, as defined in DSM-III-R, was diagnosed (with a structured interview) in only seven patients (3% of total sample)---one of the 41 AN, one of the 98 BN, and five of 90 mixed AN/BN patients. Krahn et al. 19 classified patients as stealers if, in an interview, they answered "yes" on the question: "Since the onset of your eating problem, have you been involved in stealing?" A history of stealing was admitted in 28.2% of the total sample--6.3% of 16 AN patients, 30.8% of 13 patients with AN and BN, and 32.6% of 95 BN patients. Of the 57 patients with eating disorder NOS (which included primarily patients who did not meet the criterion of binge-eating frequency for BN), 26.3% also reported a history of stealing. Stealers showed greater psychopathology (SCL-90), higher scores on the Michigan Alcoholism Screening Test, and greater dysfunctional eating and purging behaviors, although they did not differ from nonstealers on the Eating Disorder Inventory. In a study of "repetitive behavior" in 65 BN patients, Christenson and Mitchell 2° found 12% reported "compulsive stealing" (no details given) on a written survey. In a study of self-damaging and addictive behavior (semistructured interview) in 112 bulimic women stemming from the same catchment area, Lacey21 reported that 41% gave a history of stealing; 21% had stolen on two or more occasions. Of the 46 stealers, 20 were shoplifters (mainly in food shops) and 16 had stolen money from family or friends. Only two had been prosecuted. Repeated stealing did not occur as an isolated behavior, but always in the presence of overdosing or alcohol/drug abuse. Lacey called these BN patients "multiimpulsive bulimics." Fichter et al. 22 examined this subtype, i.e., BN and an additional impulsive behavior (suicide attempt, alcohol/drug abuse, autoaggressive behavior, promiscuity, or stealing), and found the lifetime incidence for shoplifting (other than food) was 34.7%. These "impulsive" bulimics (all admitted at a specialized treatment center) showed greater general
VANDEREYCKEN AND V A N HOUDENHOVE
psychopathology and had an overall less favorable course of illness. The summary in Table 3 shows that the best comparison between studies can be made for BN patients. The low figure in the study by Christenson and Mitchell 2° might be attributed to their stricter definition of "compulsive stealing" and/or to the fact that they recruited their sample through advertisement. The restrictive definition of stealing used by Krahn et a13 9 and Fichter et al.22--the latter had also selected a sample of "impulsive" bulimics--might explain their figures being somewhat lower than those found by Lacey21 and in the present study. However, all studies showed the same basic finding: stealing is more likely when the eating disorder includes "bulimia-like" behavior (binge eating, vomiting, and laxative abuse). Krahn et al. 19 and Fichter et al. 22 concluded that stealing is related to greater psychopathology. We could confirm this only with regard to dissociative experiences. Generally speaking, stealing behavior seems to express some form of loss of control or impulsivity. However, it most often appears to be related to the eating disorder itself, although in several cases it may involve "ordinary" shoplifting. In this respect, Mitchell et a153 published an interesting comparison of the stealing patterns of 27 bulimic and 25 nonbulimic shoplifters. The majority of the bulimic shoplifters reported stealing something which was involved with their eating disorder (e.g., food, money, laxatives, diuretics, or diet pills), and they indicated that embarrassment over buying these items was the main reason to shoplift. The nonbulimic shoplifters, on the other hand, were more likely to endorse Table 3. Stealing in Eating Disorders: A Comparison o f Studies Study
Pure AN
Mixed AN
BN
Krahn et al. (1992)*
6.3%
30.8%
32.6%
Garner et al. (1993)
2.0%
12.0%1"
--
Christenson & Mitchell (1991)¢
--
--
12.0%
Lacey (1993)
--
--
41.0%
Fichter et al. (1994)§
--
--
34.7%
35.3%
54.8%
48.7%
Present study
*Stealing since the onset of eating disorder. 1"Averaging 2 figures: 7% in purging restricters and 17% in bulimic anorectics. :l:Compulsive stealing. §Shoplifting other than food.
STEALING BEHAVIOR IN EATING DISORDERS
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reasons for stealing that one might consider antisocial, e.g., to "get back" at the store or for excitement. Krahn et al. 19 suggested that "assessing the presence or absence of associated symptoms such as stealing or other impulse control problems might be a better strategy for determining severity of the bulimic syndrome." In fact, this is in accord with the recently growing attention paid to comorbidity in eating disorders as one of the most important indicators of response to treatment and long-term outcome. According to Lacey,21 recognition of impulsive behavior "would allow the development of treatments to
deal with the interchangeable nature of the symptoms," because "only by concentrating on all the symptoms can the underlying psychopathology be tackled." These arguments should justify further systematic studies of stealing behavior in eating disorders. We hope this report will stimulate other researchers to follow our example. ACKNOWLEDGMENT The authors gratefully acknowledge the help from Johan Vanderlinden, Ph.D., Michel Probst, M.A., and Jan Norr6, M.A.
REFERENCES 1. Norton KR, Crisp AH, Bhat AV. Why do some anorexics steal? Personal, social and illness factors. J Psychiatr Res 1985;19:385-390. 2. Lee S. The heterogeneity of stealing behaviors in Chinese patients with anorexia nervosa in Hong Kong. J Nerv Ment Dis 1994;182:304-307. 3. Ziolko HU. Bulimia and kleptomania: psychodynamics of compulsive eating and stealing. In: Schwartz HJ (ed): Bulimia: Psychoanalytic Treatment and Theory. Madison, CT: International Universities Press, 1988:524-534. 4. Wellbourne J. Do bulimics really steal? Br Rev Bulimia Anorexia Nerv 1988;2:71-77. 5. McElroy SL, Hudson JI, Pope HG, Keck PE. Kleptomania: clinical characteristics and associated psychopathology. Psychol Med 1991;21:93-108. 6. McElroy SL, Pope HG, Hudson Jl, Keck PE, White KI. Kleptomania: a report of 20 cases. Am J Psychiatry 1991;148:652-657. 7. Schlosser S, Black DW, Repertinger S, Freet D. Compulsive buying: demography, phenomenology, and comorbidity in 46 subjects. Gen Hosp Psychiatry 1994;16:205212. 8. Christenson GA, Faber R J, de Zwaan M, Raymond NC, Mitchell JE. Compulsive buying: descriptive characteristics and psychiatric comorbidity. J Clin Psychiatry 1994;55: 5-11. 9. Vandcreycken W, Vanderlinden J. Denial of illness and the use of self-reporting measures in anorexia nervosa. Int J Eating Disord 1983;2:101-107. 10. Goldman MJ. Kleptomania: making sense of the nonsensical. Am J Psychiatry 1991;148:986-996. 11. Vanderlinden J, Norr6 J, Vandereycken W. A Practical Guide to the Treatment of Bulimia Nervosa. New York, NY: Brunner/Mazel, 1992. 12. Vandereycken W. The Eating Disorders Evaluation Scale. Eating Disord 1993;1:115-122.
13. Probst M, Vandereycken W, Van Coppenolle H, Vanderlinden J. The Body Attitude Test for patients with an eating disorder: psychometric characteristics of a new questionnaire. Eating Disord 1995;3:133-144. 14. Derogatis LR, Lipman RS, Rickels K, Uhlenhutz EH, Covi L. The Hopkins Symptom Checklist. Pharmacopsychotherapy 1974;17:79-110. 15. Beck AT, Ward Ch, Hendelson M, Mock JE, Erbaugh JK. An inventory for measuring depression. Arch Gen Psychiatry 1961;4:561-571. 16. Vanderlinden J, Van Dyck R, Vandereycken W, Vertommen H, Verkes RJ. The Dissociation Questionnaire (DIS-Q): development of a new self-report questionnaire, Clin Psychol Psychother 1993;1:21-27. 17. Garner DM, Garner MV, Rosen LW. Anorexia nervosa "restricters" who purge: implications for subtyping anorexia nervosa. Int J Eating Disord 1993;13:171-185. 18. Herzog DB, Keller MB, Sacks NR, Yeh CJ, Lavori PW. Psychiatric comorbidity in treatment-seeking anorexics and bulimics. J Am Acad Child Adolesc Psychiatry 1992;31: 810-818. 19. Krahn DD, Nairn K, Gosnell BA, Drewnowski A. Stealing in eating disordered patients. J Clin Psychiatry 1991;52:112-115. 20. Christenson GA, Mitchell JE. Trichotillomania and repetitive behavior in bulimia nervosa. Int J Eating Disord 1991;10:593-598. 21. Lacey JH: Self-damaging and addictive behaviour in bulimia nervosa. Br J Psychiatry 1993;163:190-194. 22. Fichter MM, Quadflieg N, Rief W. Course of multiimpulsive bulimia. Psychol Med 1994;24:591-604. 23. Mitchell JE, Fletcher L, Gibeau L, Pyle RL, Eckert E. Shoplifting in bulimia nervosa. Compr Psychiatry 1992;33: 342-345.
pared with other patients, stealers did not differ in signs of general psychopathology, but showed more abnormal scores on the DIS-Q (especially "loss of control"). The patients whose stealing was clearly related to their eating disorder did not show a distinct pattern of eating pathology or associated psychopathology. If studied in a systematic way, stealing appears to be more frequent than expected; with its relationship to bulimic tendencies and "loss of control," it might indicate a more severe (stage of an) eating disorder and, as such, deserves more attention from researchers and clinicians than the scarce literature is reflecting up to now.
N A N O R E X I A NERVOSA (AN) patients,
two major aims. Our first aim was to investigate in a systematic way the occurrence of stealing behavior in a large group of eating disorder patients. We assumed that it would be more frequent in patients who suffer from bingeeating. We also supposed that, at first assessment, patients might show a tendency to deny this behavior--especially anorectics9--and that they would be more willing to admit it after a period of treatment. Our second aim was to find various patterns of stealing behavior. We assumed that in some patients it was a wellplanned action to get food (or money to buy it), while in others it would instead have the characteristics of an impulse dyscontrol and/or show dissociative features, as in kleptomania. 1°
I stealing behavior was first connected with the sometimes strange habit of hoarding foods or objects and, as such, it was considered a form of kleptomania for which patients should be treated, not punished. 1 The association of stealing and anorectic behavior even in non-Western countries has stimulated various interpretations, ranging from biological to psychodynamic views. 2 In early reports on bulimia, a connection was made between compulsive eating and stealing. 3 Soon after the official nosographic recognition of bulimia in DSM-III, several reports made mention of stealing behavior as an aspect of "impulsivity" in these patients. 4,5 And from the opposite viewpoint, in recent years studies on kleptomania paid attention to its frequent connection with eating disorders. 6 Finally, stealing has been related to the new phenomenon of "compulsive buying"; a lifetime diagnosis of an eating disorder was found in 17% 7 to 20.8% 8 of these subjects. Inspired by these various reports, we wanted to pay more specific attention to this issue, but we soon realized that the research literature showed serious shortcomings. Therefore, we planned the present study with From the Department of Clinical Psychology, Catholic University of Leuven, Leuven, Belgium. Address reprint requests to Walter Vandereycken, M.D., Ph.D., Liefdestraat 10, 3300 Tienen, Belgium. Copyright © 1996 by W.B. Saunders Company 0010-440)(/96/3705-0001503. 00/0 316
Copyright © 1996 by W.B. Saunders Company
METHOD
Subjects One hundred fifty-five females meeting DSM-III-R criteria for eating disorders (the only selection criterion) were recruited from three different treatment settings: 65 had been admitted to a specialized eating disorders unit of a university hospital, 56 were inpatients at a behavior therapy unit of a general psychiatric hospital known for treating eating disorders, and 34 were outpatients from a private practice of a clinical psychologist specializing in the treatment of eating disorders. The cases of AN were subdivided (in accordance with DSM-IV subtyping) into a "restricting" type or pure fasters (n = 51), and a "mixed" type with binge-eating and/or vomiting/purging (n = 62). Of the 39 bulimia nervosa (BN) patients, 10 were at least 15% overweight. Three patients were diagnosed as "eating disorder not otherwise specified" (NOS). 11 Except for obvious features (such as weight and eating behavior), there were no significant differences between restricting AN, mixed AN,
ComprehensivePsychiatry, VoI. 37, No. 5 (September/October), 1996: pp 316-321
STEALING BEHAVIOR IN EATING DISORDERS
and BN with respect to age (mean_ SD, 23.5 _+ 7.3 v 22.5 -+ 5.7 v 23.0 ± 3.8 years, respectively) or duration of illness (5.9 ___5.4 v 4.7 --_3.5 v 5.3 ± 3.2 years). Although applied in different settings, the basic ideas of the multidimensional therapy were the same for all patients; all therapists were trained and supervised by one of us (W.V.).11
Procedure All data were gathered and analyzed by a female researcher (V.V.H.), who was not involved in the treatment. Confidentiality of the results was guaranteed to all patients. (It was explicitly stated that their therapists would not be informed.) At first assessment, before starting treatment, all patients were asked to complete a series of self-reporting questionnaires. The first set of validated questionnaires was aimed at assessing features directly related to the eating disorder itself. The Eating Disorder Evaluation Scale (EDES) 12is an easy and comprehensive self-reporting instrument for the clinical judgment of the severity of eating disorders containing four subscales: anorectic preoccupation, bulimic behavior, sexuality, and psychosocial adjustment. The Body Attitude Test (BAT) 13 is a self-reporting questionnaire developed for female patients suffering from eating disorders. It measures three aspects of body experience: negative appreciation of body size, lack of familiarity with one's own body, and general body dissatisfaction. The second set of self-reporting instruments was chosen to assess psychopathology in general and specific comorbidity in particular. The Symptom Checklist (SCL-90) 14 is a well-known measure for the assessment of a wide array of psychiatric symptoms (e.g., anxiety, depression, somatization, sensitivity, and hostility). Another "classic" instrument is the Beck Depression Inventory (BDI), 15which measures the degree of depression. The Dissociation Questionnaire (DIS-Q) 16 is aimed at assessing dissociative experiences: identity confusion and fragmentation (referring to experiences of depersonalization and derealization), loss of control (over one's behavior, thoughts, and emotions), amnesia (memory lacunas), and absorption. Finally, for the purpose of this study we developed an exploratory instrument--the Stealing Behavior Questionnaire (SBQ). The subject is first asked whether he/she has ever stolen anything. In the introduction, it is stated: "With stealing we mean taking without permission any object, regardless of its value, that doesn't belong to you. If this happened at your (family's) home it should also be considered as stealing, except for foods and drinks." If the subject answered "no," he/she was then asked: "Have you ever felt the urge to steal, without doing it?" The type and content of the other questions is described in The Results section. A group of 80 patients was asked to complete the SBQ a second :time after about 2 months (the period during which all were either in inpatient treatment or weekly outpatient psychotherapy). RESULTS
First Versus Second Assessment In a first step, we c o m p a r e d the results on the S B Q at first a s s e s s m e n t a n d a f t e r 2 m o n t h s '
317
t r e a t m e n t (n = 80). Surprisingly, t h e r e w e r e a l m o s t no d i f f e r e n c e s in t h e a d m i t t a n c e o f stealing: t h r e e p a t i e n t s c h a n g e d t h e i r a n s w e r from " y e s " to " n o , " a n d two p a t i e n t s d i d the o p p o s i t e . Also, with r e g a r d to m o r e c o n c r e t e facts o f stealing (e.g., frequency, places, ages, a n d objects), p r a c t i c a l l y no m e a n i n g f u l c h a n g e s in answers w e r e found. Twelve p a t i e n t s ( 1 5 % ) a d m i t t e d at s e c o n d a s s e s s m e n t a g r e a t e r freq u e n c y of stealing d u r i n g t h e p a s t year; this could b e i n t e r p r e t e d as a sign of g r e a t e r h o n e s t y a n d / o r m o r e stealing in the p e r i o d since t h e first a s s e s s m e n t (the S B Q now c o v e r e d t h e s e 2 treatment months). On the question of whether they h a d t a l k e d with s o m e o n e a b o u t t h e i r stealing, 10 (12.5%) p a t i e n t s c h a n g e d t h e i r a n s w e r f r o m " n o " to " y e s , " a n d 16 ( 2 0 % ) now i n c l u d e d a t h e r a p i s t in t h e list o f p e r s o n s with w h o m t h e y h a d s p o k e n a b o u t it. W i t h r e s p e c t to q u e s t i o n s r e l a t e d to feelings a n d t h o u g h t s a b o u t t h e stealing, 25% o f t h e p a t i e n t s a n s w e r e d differently t h e s e c o n d time, showing m o r e "psychological insight."
Characteristics of Stealers S e v e n t y - t h r e e p a t i e n t s (47.1%) a d m i t t e d to having stolen (we will r e f e r to t h e m as " s t e a l ers"), i n c l u d i n g 35.3% o f restricting A N , 54.8% of m i x e d A N , a n d 48.7% o f B N p a t i e n t s . O n l y t h e difference b e t w e e n r e s t r i c t i n g a n d m i x e d A N r e a c h e d statistical significance (P < .05). T h e r e was no significant d i f f e r e n c e with r e s p e c t to the clinical setting. O f t h e p a t i e n t s who r e p o r t e d n e v e r to have stolen, 8.5% a d m i t t e d t h e y o n c e h a d t h e urge to do it. C o m p a r e d with the o t h e r p a t i e n t s , t h e s t e a l e r s d i d n o t differ in age, b u t t h e i r m e a n d u r a t i o n o f illness was g r e a t e r (5.8 --- 4.1 v 4.3 _+ 4.2 years, P < .05) a n d a s m a l l e r p r o p o r t i o n was m a r r i e d (9.9% v 1 6 . 7 % , P < .01). On the self-reporting questionnaires related to a s p e c t s o f the e a t i n g d i s o r d e r ( E D E S a n d B A T ) , no significant differences w e r e found, with o n e i m p o r t a n t e x c e p t i o n : on the b u l i m i a subscale o f the E D E S , the stealers s c o r e d significantly (P < .0001) lower (i.e., m o r e a b n o r m a l ) t h a n the o t h e r s (9.8 + 5.0 v 13.4 -+ 5.2). W i t h r e g a r d to various p s y c h o p a t h o l o g i c a l c o m p l a i n t s (SCL-90) o r d e p r e s s i o n ( B D I ) , no significant differences w e r e found. H o w e v e r , the stealers showed more pronounced features
318
VANDEREYCKEN AND VAN HOUDENHOVE
of dissociative experiences and behaviors, with the most distinct difference on the DIS-Q "loss of control" subscale (Table 1).
Aspects of Stealing Details about the stealing behavior are summarized in Table 2. In about 45% of the cases, stealing started before the eating disorder, and in more than half of the patients it occurred more than once during the past year. It mostly concerned food and/or money, and most often occurred at home or in a shop. About 40% of the stealers have been caught at least once, and for half of them this happened in a shop or supermarket (one third were fined). In about one third, the stolen object was not the main motive, but rather the act of stealing itself had a special meaning.
Types of Stealers Combining three questions--stolen object, motive for stealing, and patient's idea about relationship to AN/BN--two independent assessors reached a correspondence of 93.2% in subdividing the sample according to whether the stealing was related (group A, 62.5%) versus unrelated (group B, 37.5%) to an eating disorder. (One case was dropped for lack of important information.) Except for the aspects directly related to the subgrouping, in most group A cases stealing still occurred during the past year and in a marked frequency. They also stole more from friends, felt less guilty before but more excited or confused during stealing, and only half of them were convinced that stealing would not occur again. With respect to age, marital status, duration of illness, body mass index, and treatment setting, no significant differences were shown between group A and B. The same applied to the scores on all questionnaires (EDES, BAT, SCL-90, DIS-Q, and BDI). Table 1. Scores on the DIS-Q Mean +_SD DIS-Q Scale
Stealers(n = 73)
Nonstealers(n = 82)
P .0020
Total
2.29 _+ 0.63
1.87 -+ 0,43
Confusion
2.37 _+ 0.78
1.89 _+ 0,59
.0007
Loss of control Amnesia Absorption
2.52 -+ 0.77
2.00 +- 0.54
.0002
1.65 --. 0.58
1.37 -+ 0,33
.0034
2.69 -+ 0.74
2.46 -+ 0.71
.0111
DISCUSSION
A self-report study in eating disorder patients has always to face the bias of expectancy ("social desirability") and the problem of denial, especially in AN patients. 9 One might expect that such a distortion of answering patterns a fortiori would take place when patients are questioned about a socially unacceptable behavior such as stealing. We supposed that some eating disorder patients would first need to build up a trustful therapeutic relationship and/or gain some psychological insight before being ready to reveal information which would bring them in a vulnerable position. However, at second assessment--after 2 months' intensive treatment--virtually the same number of patients admitted stealing. On the other hand, changes in the content of some answers may be influenced by the ongoing treatment, which elicits a greater openness, and different feelings and thoughts about stealing and its significance. The limited influence of therapy on answers to the SBQ might be related to the selection of our sample: the majority of patients had been in treatment elsewhere and were ready now to engage in a specialized and demanding treatment. Hence, our patients might have shown a more than average willingness (and "psychological insight") to reveal delicate information about themselves. Differences between this and other studies may also be due to the definition of stealing and the assessment method. (We preferred an anonymous questionnaire instead of the more "embarrassing" confrontation with an interviewer.) Another stumbling block in comparing data is the diagnostic criteria used. Even if we only look at studies in which at least DSM-III-R criteria have been used (as the definition of bulimia in DSM-III was too broad), there remains the problem of subdividing AN. The problem with most preDSM-IV studies is that if they speak about "mixed" AN they refer to binge-eating anorectics and thus include the nonbulimic purging anorectics within the "restricting" type. Garner et al. 17 have clearly demonstrated that purging behavior (i.e., self-induced vomiting and/or laxative abuse) is an important distinguishing characteristic regardless of whether or not AN anorectics report binge-eating. Although details are lacking, these authors re-
STEALING BEHAVIOR IN EATING DISORDERS
319
Table 2. Aspects of Stealing (Cont'd)
Table 2. Aspects of Stealing Total Question/Response
No.
(%)
Group A No.
(%)
Total
Group B No.
(%)
P*
First time, how long ago? <5yr 5tol0yr >10yr Last time, how long ago? <4mo 4tol0mo >10mo Total number of times Once 2 t o 5times >5times Frequency in past year None 1 to l 0 t i m e s >Onceamonth >Onceaweek Goods stolent Food items Money Toilet items, clothes Others Use of stolen goods1" Used it Kept without use Given away or restored Thrown away Where or from whom?? Parents, siblings Other family or friends Shop or supermarket School or w o r k site Others Did you plan it? Notatall Moreorless Well planned Feelings just beforet Tense Anxious Guilty Depressed Others* Feelings during stealingt Tense Anxious Guilty Depressed Others*
n 29 20 24
=73 n=45 n=27 (39.7) 20 (44.4) 9 (33.3) (27.4) 12 (26.7) 7 (25.9) (32.9) 13 (28.9) 11 (40.8)
n = 66 28 (42.4) 7 (10.6) 31 (47.0) n=73 14 (19.2) 24 (32.9) 35 (47.9)
n = 40 n = 25 <.001 22 (55.0) 6 (24.0) 7 (17.5) 0 - 11 (27.5) 19 (76.0) n=45 n=27 <.001 0 -13 (48.2) 17 (37.8) 7 (25.9) 28 (62.2) 7 (25.9)
n 33 25 7 8 n 44 23 17 24 n 62 12
n 12 18 7 8 n 36 14 9 15 n 42 9
= 73 (45.2) (34.2) (9.6) (11.0) = 68 (64.7) (33.8) (25.0) (35.3) = 71 (87.3) (16.9)
11 (15.5) 5 (7.0)
= 45 n = 27 <.001 (26.7) 20 (74.1) (40.0) 7 (25.9) (15.5) 0 - (17.8) 0 - = 45 n = 22 (80.0) 7 (31.8) <,001 (31.1) 9 (40.9) (20.0) 8 (36.4) (33.3) 9 (40.9) = 45 n = 25 (93.3) 19 (76.0) <,05 (20.0) 3 (12.0)
6 (13.3) 4 (8.9)
5 (20.0) 1 (4.0)
n = 72 n = 45 n = 26 28 (40.0) 18 (40.0) 11 (42.3) 22 (31.4) 18 (40.0) 31 13 9 n 45 21 4 n 38 30 12 12 24
(44.3) (18.6) (12.9) = 70 (64.3) (30.0) (5.7) = 58 (65.5) (51.7) (20.7) (20.7) (41.4)
n=68 49 (72.1) 45 (66.2) 19 (27.9) 5 (7.4) 25 (36.8)
17 10 8 n 26 16 3 n 25 22 5 9 18
4 (15.4) <.005
(37.8) 14 (53.8) (22.2) 3 (11.5) (17.8) 1 (3.8) = 45 n = 24 (57.8) 18 (75.0) (35.5) 5 (20.8) (6.7) 1 (4.2) = 40 n = 17 (62.5) 13 (76.5) (55.0) 8 (47.1) (12.5) 7 (41.2) <.001 (22.5) 3 (17.6) (45.0) 6 (35.3)
n=45 n =22 36 (80.0) 12 (54.5) <.001 27 (60.0) 17 (77.3) 11 (24.4) 8 (36.4) 3 (6.7) 2 (9.1) 21 (46.7) 4 (18.2) <.001
Group A
Question/Response
No.
(%)
No.
Feelings afterwardst Tense Anxious Guilty Depressed Others:l: Have you ever been caught? Never Yes, at least once Yes, more than once To w h o m did you reveal it? Noone Family member Spouse or boyfriend Friend Therapist Stealing in the future§ Neveragain Very unlikely Might happen again Don't k n o w Reason for stealingt Togetfood Lack of money Anger or revenge For fun or sensation Uncontrollable urge Related to eating disorders?ll Notatall Possibly Certainly No idea
n 26 37 60 21 26
= 68 (38.2) (54.4) (88.2) (30.9) (38.2)
n 17 25 38 15 19
(%)
Group B No.
(%)
P*
= 44 n = 23 (38.6) 8 (34.8) (56.8) 12 (52.2) (86.4) 21 (91.5) (34.1) 6 (26.1) (43.2) 7 (30.4)
n = 73 n = 45 n = 27 44 (60.3) 24 (53.3) 19 (70.4) 29 (39.7) 21 (46.7) 8 (29.6) 12 (16.4)
9 (20.0)
3 (11.1)
n = 72 n = 45 n = 26 26 (36.1) 14 (31.1) 12 (46.1) 25 (34.7) 19 (42,2) 6 (23.1) 11 25 16 n 28 17 14 14 n 27 19 14 11 9
(15.3) (34.7) (22.2) = 73 (38.4) (23.3) (19.2) (19.2) = 70 (38.6) (27.1) (20.0) (15.7) (12.9)
6 14 14 n 10 11 12 12 n 24 13 9 4 9
(13,3) 5 (19.2) (31,1) 10 (38.5) (31.1) 2 (7.7) = 45 n = 27 <.01 (22.2) 17 (63.0) (24.4) 6 (22.2) (26.7) 2 (7.4) (26.7) 2 (7.4) = 45 n = 24 (53.3) 3 (12.5) <,001 (28.9) 6 (25.0) (20.0) 5 (20.8) (8.9) 6 (25.0) (20.0) 0 - <.05
n 20 15 33 3
= 71 n = 45 n = 25 <.001 (28.2) 5 (11.1) 14 (56.0) (21.1) 10 (22.2) 5 (20.0) (46.5) 28 (62.2) 5 (20.0) (4.2) 2 (4.5) 1 (4.0)
NOTE. Group A, stealing related to eating disorder; group B, other form of stealing. *A v B, X2 test. Percentages refer to the group of stealers only. t O n these questions, the patient could mark more than 1 possibility. t o t h e r feelings included excited, confused, or ashamed. §Do you think that, in the future, stealing could happen to you again? IIDo you think that stealing (or the urge to do it) has something to do with having an eating disorder?
ported the following figures on "history of stealing" in AN subgroups (data on a large sample of patients attending a specialized treatment program): 2% in nonpurging restricters, 7% in purging restricters, and 17% in bulimic anorectics. 17 If we take DSM-III-R criteria as basis for a
320
comparison, only a few studies have systematically examined stealing behavior in eating disorders. Current and lifetime psychiatric diagnoses in 229 female patients seeking treatment for an eating disorder have been studied by Herzog et al. 18 Kleptomania, as defined in DSM-III-R, was diagnosed (with a structured interview) in only seven patients (3% of total sample)---one of the 41 AN, one of the 98 BN, and five of 90 mixed AN/BN patients. Krahn et al. 19 classified patients as stealers if, in an interview, they answered "yes" on the question: "Since the onset of your eating problem, have you been involved in stealing?" A history of stealing was admitted in 28.2% of the total sample--6.3% of 16 AN patients, 30.8% of 13 patients with AN and BN, and 32.6% of 95 BN patients. Of the 57 patients with eating disorder NOS (which included primarily patients who did not meet the criterion of binge-eating frequency for BN), 26.3% also reported a history of stealing. Stealers showed greater psychopathology (SCL-90), higher scores on the Michigan Alcoholism Screening Test, and greater dysfunctional eating and purging behaviors, although they did not differ from nonstealers on the Eating Disorder Inventory. In a study of "repetitive behavior" in 65 BN patients, Christenson and Mitchell 2° found 12% reported "compulsive stealing" (no details given) on a written survey. In a study of self-damaging and addictive behavior (semistructured interview) in 112 bulimic women stemming from the same catchment area, Lacey21 reported that 41% gave a history of stealing; 21% had stolen on two or more occasions. Of the 46 stealers, 20 were shoplifters (mainly in food shops) and 16 had stolen money from family or friends. Only two had been prosecuted. Repeated stealing did not occur as an isolated behavior, but always in the presence of overdosing or alcohol/drug abuse. Lacey called these BN patients "multiimpulsive bulimics." Fichter et al. 22 examined this subtype, i.e., BN and an additional impulsive behavior (suicide attempt, alcohol/drug abuse, autoaggressive behavior, promiscuity, or stealing), and found the lifetime incidence for shoplifting (other than food) was 34.7%. These "impulsive" bulimics (all admitted at a specialized treatment center) showed greater general
VANDEREYCKEN AND V A N HOUDENHOVE
psychopathology and had an overall less favorable course of illness. The summary in Table 3 shows that the best comparison between studies can be made for BN patients. The low figure in the study by Christenson and Mitchell 2° might be attributed to their stricter definition of "compulsive stealing" and/or to the fact that they recruited their sample through advertisement. The restrictive definition of stealing used by Krahn et a13 9 and Fichter et al.22--the latter had also selected a sample of "impulsive" bulimics--might explain their figures being somewhat lower than those found by Lacey21 and in the present study. However, all studies showed the same basic finding: stealing is more likely when the eating disorder includes "bulimia-like" behavior (binge eating, vomiting, and laxative abuse). Krahn et al. 19 and Fichter et al. 22 concluded that stealing is related to greater psychopathology. We could confirm this only with regard to dissociative experiences. Generally speaking, stealing behavior seems to express some form of loss of control or impulsivity. However, it most often appears to be related to the eating disorder itself, although in several cases it may involve "ordinary" shoplifting. In this respect, Mitchell et a153 published an interesting comparison of the stealing patterns of 27 bulimic and 25 nonbulimic shoplifters. The majority of the bulimic shoplifters reported stealing something which was involved with their eating disorder (e.g., food, money, laxatives, diuretics, or diet pills), and they indicated that embarrassment over buying these items was the main reason to shoplift. The nonbulimic shoplifters, on the other hand, were more likely to endorse Table 3. Stealing in Eating Disorders: A Comparison o f Studies Study
Pure AN
Mixed AN
BN
Krahn et al. (1992)*
6.3%
30.8%
32.6%
Garner et al. (1993)
2.0%
12.0%1"
--
Christenson & Mitchell (1991)¢
--
--
12.0%
Lacey (1993)
--
--
41.0%
Fichter et al. (1994)§
--
--
34.7%
35.3%
54.8%
48.7%
Present study
*Stealing since the onset of eating disorder. 1"Averaging 2 figures: 7% in purging restricters and 17% in bulimic anorectics. :l:Compulsive stealing. §Shoplifting other than food.
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reasons for stealing that one might consider antisocial, e.g., to "get back" at the store or for excitement. Krahn et al. 19 suggested that "assessing the presence or absence of associated symptoms such as stealing or other impulse control problems might be a better strategy for determining severity of the bulimic syndrome." In fact, this is in accord with the recently growing attention paid to comorbidity in eating disorders as one of the most important indicators of response to treatment and long-term outcome. According to Lacey,21 recognition of impulsive behavior "would allow the development of treatments to
deal with the interchangeable nature of the symptoms," because "only by concentrating on all the symptoms can the underlying psychopathology be tackled." These arguments should justify further systematic studies of stealing behavior in eating disorders. We hope this report will stimulate other researchers to follow our example. ACKNOWLEDGMENT The authors gratefully acknowledge the help from Johan Vanderlinden, Ph.D., Michel Probst, M.A., and Jan Norr6, M.A.
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