Compulsive Buying Disorder Affects 1 in 20 Adults, Causes Marked Distress

More than 1 in 20 adults nationwide suffer from compulsive buying, according to a telephone survey of 2500 adults. And contrary to popular opinion, "compulsive buying appears to be almost as common in men as in women," according to Lorrin M. Koran, MD, first author of a recently published prevalence study of compulsive buying behavior in the United States.¹ Six percent of women and 5.5% of men in the study reported symptoms considered to be consistent with compulsive buying disorder.

These findings are significant because, as documented in previous research, a considerable amount of suffering and impairment may be associated with compulsive shopping. In addition to serious financial problems, compulsive shoppers may suffer from marked distress, and "preliminary evidence suggests that compulsive buyers suffer from abnormally high levels of depression and anxiety . . . and experience higher rates of comorbid mood and anxiety disorders than comparison groups," the study in the October issue of The American Journal of Psychiatry pointed out.

For the study, Koran and colleagues conducted a random sample, national household telephone survey in which trained laypersons interviewed 2513 adults using the clinically validated Compulsive Buying Scale (CBS) embedded in a computerized structured interview. The researchers found a point prevalence of compulsive buying of 5.8% in the survey.

According to Koran, who is emeritus professor of psychiatry and behavioral sciences at Stanford University in California, compulsive buying can be classified in the DSM-IV category of impulse control disorder not otherwise specified, although it is not actually mentioned in DSM-IV. Proposed diagnostic criteria include being frequently preoccupied with buying or subject to irresistible, intrusive, and/or senseless impulses to buy; frequently buying unneeded items or more than can be afforded; shopping for periods longer than intended; and experiencing adverse consequences, such as marked distress, impaired social or occupational functioning, and/or financial problems.²

"Compulsive shoppers are actively acquiring the items, but they don't care about them after they have them," Koran told Psychiatric Times. "Women will hang new clothes in the closet, yet never take them out of the bag and never take off the tags. Men will leave the CDs wrapped in plastic and never listen to them." According to earlier research, men tend to buy electronic gadgets, tools, books, and compact discs, while women tend to buy clothes, makeup, craft items, and objects for the home.

In the prevalence study, compulsive buying behavior was associated with substantial financial adverse effects in every income group, Koran added. Compared with other respondents, compulsive buyers were more likely to have their credit cards within $500 and $100 of their credit limit and were 4 times as likely to "very often" or "often" make the minimum payment on credit card balances. Compulsive buyers also were younger and more likely to have reported incomes under $50,000.

Compulsive buying is "not a trivial disorder in its own right," Koran said. Adverse consequences have included bankruptcy, family conflict, divorce, illegal activities, and suicide attempts.¹

Comorbidity
In the treatment studies he has conducted, Koran said that about one quarter to one third of the compulsive buyers have major depression, but it is unclear "which way the causality runs." Among patients he has treated with both disorders, he added, the depression might respond without the compulsive shopping responding or vice versa.

Other frequent comorbidities are anxiety disorders and impulse control disorders, such as trichotillomania, compulsive gambling, and skin picking.

"Since the impulse control disorders tend to go together, just like the anxiety disorders tend to go together, it would be useful to screen anyone with an impulse control disorder for comorbid compulsive buying. It also might make sense to screen people with depression," Koran said.

The CBS,³ according to Koran, is a good screening instrument, since it has just 7 questions and is easy to answer. Still, preliminary screening can be done, he added, with just 2 questions:

• Do you find that you frequently go shopping for longer periods than you intend, with adverse consequences?
• Do you find that you frequently purchase things that you don't need, don't use, and/or can't afford?

With regard to other screening issues, Koran said it was important to screen patients with compulsive buying behaviors for bipolar disorder to ensure that the buying is not a symptom of hypomania.

Treatment approaches
Koran himself has treated some 80 compulsive buyers. His hope is that people who might have this disorder will seek help, "because treatments are available."

"Even though they haven't been proved conclusively to work," he said, "the medical experience is that treatment with either [an SSRI] or cognitive-behavioral therapy [CBT] or a combination of the two is very helpful."

Koran described one of his patients, a woman in her early 50s, who had been compulsively buying craft items since her early 20s."She filled her garage and much of her home with this material and never used it," he said. "She came into a study and responded very well to an SSRI and was able to start discarding and organizing this material and to stop buying more. . . . Her life was really changed."

Among treatments that have been evaluated for compulsive buying, according to Koran, are the SSRIs, such as fluvoxamine (Luvox), citalopram (Celexa), and escitalopram (Lexapro). A 10-week open-label trial of fluvoxamine found that 9 of 10 patients improved.⁴ However, 2 double-blind fluvoxamine trials found fluvoxamine no more effective than placebo.^5,6 The investigators hypothesized that requiring patients to keep a daily shopping log and reviewing shopping behaviors in detail at study visits may have been therapeutic elements, raising the response rate in the placebo group and obscuring a drug effect.⁷

Koran and colleagues have also researched SSRIs for treating compulsive buying. They conducted a 12-week open-label trial of citalopram, 20 to 60 mg/d, among persons who had been compulsively buying for 20 years or more and observed a marked, sustained improvement as measured both by the Yale-Brown Obsessive Compulsive Scale-Shopping Version (YBOCS-SV) and the Clinical Global Impressions- Improvement (CGI-I) scale.⁸ Seventeen of 24 subjects (71%) were classified as responders on the CGI-I. During a 12-month follow-up, those who had responded were more likely to be well at each 3-month contact point than were those who had not responded during the study.

Encouraged by the results of the open-label trial, Koran and colleagues designed a study coupling an open-label phase to identify responders to citalopram with a double-blind placebo-controlled discontinuation phase.⁷ Fifteen of 24 participants (63%) in the open-label phase met the responder criteria. Of the 15 responders who entered the double-blind treatment phase, 5 of 8 (63%) randomized to placebo relapsed, compared with 0 of the 7 randomized to continue citalopram.

Koran added that there is an identical study using escitalopram in press, but the results are not available yet. He also has used naltrexone (ReVia) in his clinical practice with 2 patients who did not respond to SSRIs and found that the drug helped.

"None of these studies are large enough to claim that the treatments have been demonstrated to be effective," Koran pointed out. "What one can say is that they appear to be effective for some patients."

Beyond medications, Koran said that a just-published study by Mitchell and colleagues⁹ found that CBT delivered in a group format may be efficacious for treating compulsive buying disorder. In that pilot trial, 28 patients received active treatment and 11 others served as wait-list controls. The results at the end of treatment showed significant advantages for CBT over the wait-list group in reductions in the number of compulsive buying episodes and time spent buying, as well as scores on the CBS and YBOCS-SV.

Medicalizing a behavior?
When Koran and colleagues' recent article was published, there was an accompanying editorial by Eric Hollander, MD, and Andrea Allen, PhD.¹⁰ Some critics, Hollander and Allen said, have warned that classifying compulsive buying as a psychiatric disorder is like medicalizing a "moral" problem or creating a new disorder to sell more pharmaceuticals.When asked about the criticism, Koran responded: "The same can be said about alcoholism and gambling. These are behaviors that meet the criteria of causing substantial distress and dysfunction." Compulsive buying, he added, seems to meet criteria that would be used to classify other behaviors as mental disorders. As with those disorders, the question of whether there is a legal responsibility connected with compulsive buying, such as whether compulsive buyers should be allowed to declare bankruptcy, is a social consensus decision.

In their editorial, Hollander and Allen acknowledged that viewing compulsive buying from a medical perspective and as a diagnosable mental disorder has some advantages.

"It might facilitate routine screening for the condition by mental health professionals and perhaps even inclusion of the disorder in national prevalence surveys, which would help define the true prevalence of the disorder," they said. "It might also lead to the study of vulnerability factors for the development of the disorder, better characterization of brain-based circuits, and development of effective psychosocial and medication treatments."¹⁰

Asked about the controversy concerning which category compulsive buying should be under in the proposed DSM-V, Koran told Psychiatric Times it should remain as an impulse control disorder, since it has the phenomenologic qualities of this type of disorder.

"It is associated with tension beforehand, pleasure or gratification during the act, and then remorse, regret, or guilt afterward because of the problems it creates," he explained.

To further research compulsive buying, Koran said that he and his team will be looking at whether a biologic abnormality can be identified in the people who have the disorder or in those who have the disorder and respond to medication, as opposed to ones who do not respond to medication.

References:

References1. Koran LM, Faber RJ, Aboujaoude E, et al. Estimated prevalence of compulsive buying behavior in the United States. Am J Psychiatry. 2006;163:1806-1812.
2. McElroy SL, Keck PE Jr, Pope HG Jr, et al. Compulsive buying: a report of 20 cases. J Clin Psychiatry. 1994;55: 242-248.
3. Faber RJ, O'Guinn TC. A clinical screener for compulsive buying. J Consumer Res. 1992;19:459-469.
4. Black DW, Monahan P, Gabel J. Fluvoxamine in the treatment of compulsive buying. J Clin Psychiatry. 1997; 58:159-163.
5. Black DW, Gabel J, Hansen J, Schlosser S. A double-blind comparison of fluvoxamine versus placebo in the treatment of compulsive buying disorder. Ann Clin Psychiatry. 2000;12:205-211.
6. Ninan PT, McElroy SL, Kane CP, et al. Placebo-controlled study of fluvoxamine in the treatment of patients with compulsive buying. J Clin Psychopharmacol. 2000; 20:362-366.
7. Koran LM, Chuong HW, Bullock KD, Smith SC. Citalopram for compulsive shopping disorder: an open-label study followed by double-blind discontinuation. J Clin Psychiatry. 2003;64:793-798.
8. Koran LM, Bullock KD, Hartston HJ, et al. Citalopram treatment of compulsive shopping: an open-label study. J Clin Psychiatry. 2002;63:704-708.
9. Mitchell JE, Burgard M, Faber R, et al. Cognitive behavioral therapy for compulsive buying disorder. Behav Res Ther. 2006;44:1859-1865.
10. Hollander E, Allen A. Is compulsive buying a real disorder, and is it really compulsive? Am J Psychiatry. 2006; 163:1670-1672.