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Compulsive Buying Disorder: A Review of the Evidence


Donald W. Black, MD


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CNS Spectr. 2007;12(2):124-132

Faculty Disclosures and Affilations

Dr. Black is professor of psychiatry in the Department of Psychiatry at the University of Iowa Roy J. and Lucille A. Carver College of Medicine in Iowa City.

Disclosures: Dr. Black is on the speaker’s bureaus of Forest, Pfizer, and Shire; has received grant/research support from Forest and Shire; and has received honoraria from Forest, Pfizer, and Shire.

Submitted for publication: November 21, 2006; Accepted for publication: January 3, 2007.

Please direct all correspondence to: Donald W. Black, MD, Psychiatry Research/2-126B MEB, University of Iowa Carver College of Medicine, Iowa City, IA 52242; Tel: 319-353-4431, Fax: 319-353-3003; E-mail: donald-black@uiowa.edu.

Focus Points

 

• Compulsive buying disorder is common and widespread, and is best classified as a disorder of impulse control.
• Compulsive buying disorder has an onset in an individuals late teens/early twenties and seems chronic.
• Developmental, neurobiologic, and cultural explanations have been proposed as etiologic factors in the development of compulsive buying disorder.
• Compulsive buying disorder is associated with comorbid mood, anxiety, substance use, eating, and impulse-control disorders.
• There is no standard treatment for compulsive buying disorder, but cognitive-behavioral group models seem promising, and psychopharmacologic treatments are being actively studied.


Abstract

Compulsive buying disorder is characterized by excessive or poorly controlled preoccupations, urges, or behaviors regarding shopping and spending that lead to subjective distress or impaired functioning. Compulsive buying disorder is estimated to have a lifetime prevalence of 5.8% in the United States general adult population. In clinical settings, most individuals with compulsive buying disorder are women (~80%). This gender difference may be artifactual. Compulsive buying disorder is typically chronic or intermittent, with an age of onset in the late teens or early 20s. Comorbid mood and anxiety disorders, substance use disorders, eating disorders, and other disorders of impulse control are common, as are Axis II disorders. The disorder occurs worldwide, mainly in developed countries with market-based economies, and it tends to run in families with mood disorders and substance abuse. There is no standard treatment for compulsive buying disorder, but group cognitive-behavioral models seem promising, and psychopharmacologic treatments are being actively studied. Other treatment options include simplicity circles, 12-step programs, financial counseling, bibliotherapy, marital therapy, and financial counseling. Directions for future research are discussed.

Introduction

Examples of profligate spending have been reported for centuries, including the well known excesses of Marie Antoinette, Mary Todd Lincoln, William Randolph Hearst, and, more recently, Jacqueline Kennedy Onassis, and Princess Diana.1-5 Whether these individuals had a compulsive buying disorder is a matter of debate, yet all were observed to have episodes of excessive and sometimes senseless spending that contributed to their financial downfall or personal problems, or in the case of Marie Antoinette, her life.

Compulsive buying disorder has been considered a clinical entity since the early 20th century, when descriptive psychiatrists including Bleuler6 and Kraepelin7 included compulsive buying disorder in their respective textbooks. Bleuler considered compulsive buying disorder, or “oniomania,” an example of a reactive impulse, or impulsive insanity, and placed it alongside kleptomania and pyromania.6 Little attention was paid to this disorder over the years except for rare clinical case presentations in the psychoanalytic literature,8-10 or by researchers interested in consumer behavior.11,12 Clinical interest was revived in the early 1990s, when clinical case series involving 90 individuals were reported from three independent research groups.13-15  

Debate continues to swirl around its appropriate classification. Some researchers have linked compulsive buying disorder to addictive disorders,16 grouping it alongside alcohol and drug use disorders. Others have linked compulsive buying disorder to obsessive-compulsive disorder (OCD),17 and still others to mood disorders.18 Its various names recognize the different ways in which it is regarded: compulsive shopping, addictive shopping, shopaholism, compulsive buying, and even mall mania. Researchers19 have decried the attempts to categorize compulsive buying disorder as an illness, which they see as part of an unfortunate trend to “medicalize” behavioral problems. More recently, it has been suggested the disorder be included in a new diagnostic category combining behavioral and substance addictions.20 In this model, “behavioral addictions” would include pathological gambling, kleptomania, pyromania, compulsive buying disorder, Internet addiction, and compulsive sexual behavior. In fact, the National Institute on Drug Abuse considers behavioral addictions to be relatively pure models of addiction because they are not contaminated by the presence of an exogenous substance.21

The classification of compulsive buying disorder remains elusive. This condition was included in the Diagnostic and Statistical Manual of Mental Disorders, Third Edition-Revised as an example of an impulse-control disorder not otherwise specified, yet the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition-Text Revision is silent on the issue, and compulsive buying disorder remains an orphan disorder.22,23 McElroy and colleagues13 have developed a set of operational criteria for use in research settings which emphasize cognitive and behavioral aspects of the disorder, as well as impairment characterized by marked subjective distress, interference in social or occupational functioning, or financial/legal problems; mania and hypomania should have been ruled out as causes of the disorder. These criteria have become the standard in compulsive buying disorder research, despite the fact that neither their reliability nor validity have been established.

Epidemiology

Faber and O’Guinn24 estimated the prevalence of compulsive buying disorder to fall between 2% and 8% of the general population, based on results of a survey in which the Compulsive Buying Scale (CBS)25 was administered to 292 individuals in Illinois. Recently, Koran and colleagues,26 who also used the CBS to identify compulsive buyers, estimated the point prevalence of compulsive buying disorder at 5.8% of respondents based on results from a random telephone survey of 2,513 adults. The estimate was calculated by using CBS scores two standard deviations below the mean. A prevalence of 1.4% was calculated using the even stricter criterion of three standard deviations below the mean. Two small scale surveys suggest an even higher prevalence figures ranging from 12% to 16%.27,28 Grant and colleagues29 recently reported a lifetime prevalence rate of 9.3% for compulsive buying disorder among 204 consecutively admitted psychiatric inpatients. Despite the growing scientific interest and intense media attention directed at the disorder, there is no evidence that compulsive buying disorder is increasing in prevalence.

Community-based studies, and the survey results suggest that from 80% to 94% of persons with compulsive buying disorder are women (Table 1).13-15,24 Yet, Koran and colleagues26 reported that the prevalence of compulsive buying disorder is nearly equal in men and women (5.5% and 6.0%, respectively). This finding suggests that the reported gender difference could be artifactual, and perhaps stem from the fact that women appear to readily acknowledge that they enjoy shopping, whereas men are more likely to report that they “collect.” On the other hand, Dittmar30 concluded that the gender difference is real and is not an artifact of men being underrepresented in samples. She based her conclusion on the results of a general population survey in the United Kingdom in which 92% of respondents considered compulsive shoppers were women.

The age of onset has ranged from 18–30 years in clinical studies (Table 1). The ages likely differ to some extent because of the way the samples were selected. For example, Christenson and colleagues14 reported an age of onset at 18 years and had advertised for study participants whereas McElroy and colleagues13 reported a mean age of onset of 30 years, but recruited persons with compulsive buying disorder who had been in treatment with a psychotherapist. It may be that the age of onset corresponds with emancipation from the nuclear family, as well as the age at which people first establish credit accounts.



There are no careful longitudinal studies of compulsive buying disorder, but 59% of subjects studied by Schlosser and colleagues15 described their course as continuous, while 41% described it as episodic. Similarly, McElroy and colleagues13 reported that 60% of subjects in their study described their course as chronic and 8% as episodic. More recently, Aboujaoude and colleagues31 suggested that individuals who responded to treatment with citalopram were likely to remain in remission during 1-year follow-up suggesting the treatment could alter the natural history of the disorder. The author has observed that subjects with compulsive buying disorder typically report decades of compulsive shopping behavior, yet it could be that clinical samples are biased in favor of severity.

Clinical Symptoms

Persons with compulsive buying disorder are preoccupied with shopping and spending, and typically spend many hours each week engaged in these behaviors. Compulsive shoppers often display a great fashion sense and have an intense interest in new clothing styles and products. While it may be argued that a person could be a compulsive shopper and not spend, confining their interest to window shopping, this pattern is uncommon in the author’s experience. Persons with compulsive buying disorder often describe an increasing level of anxiety that can only be relieved when a purchase is made.

This author has observed four distinct phases of compulsive buying disorder, including anticipation, preparation, shopping, and spending. In the first phase, the person with compulsive buying disorder develops a thought or preoccupation with either having a specific item or in the act of shopping itself. This leads the individual to prepare for shopping and spending, which can entail deciding on when and where to go, how to dress, and even which credit cards to take. This phase is followed by the actual shopping experience, which many individuals with compulsive buying disorder describe as intensely exciting; some even describe experiencing a sexual feeling.15 The act is completed with the purchase, often followed by a sense of let down, or disappointment with oneself.26 Miltenberger and colleagues32 reported that negative emotions, such as anger, anxiety, boredom, and self-critical thoughts, were the most common antecedents to shopping binges in a group of persons with compulsive buying disorder, while euphoria or relief of the negative emotions were the most common consequences. Lejoyeux and colleagues18 conclude for some persons that, “uncontrolled buying, like bulimia, can be used as a compensatory mechanism for depressive feelings.”

Compulsive shopping tends to be a private pleasure, and individuals with compulsive buying disorder typically shop alone.15 Shopping may occur in just about any venue, ranging from high-end department stores and boutiques to consignment shops or garage sales. Income has relatively little to do with the existence of compulsive buying disorder, for a person with a low income can still be fully preoccupied by shopping and spending although their level of income with lead them to shop at a consignment shop rather than a department store. Great wealth does not protect against compulsive buying disorder either, as the presence of compulsive buying disorder may cause or contribute to interpersonal problems, even when it does not lead to financial problems.

Table 2 shows the types of merchandise that persons with compulsive buying disorder reported buying during shopping episodes in the studies of Christenson and colleagues14 and Schlosser and colleagues15 Favorite categories for items purchased by compulsive shoppers include clothing, shoes, jewelry, make-up, and compact discs. Anecdotally, patients often report buying a product based on its attractiveness or because it was a bargain. In a study by Christenson and colleagues,14 compulsive shoppers reported spending an average of $110 during a typical shopping episode compared with $92 reported in the study by Schlosser and colleagues.15



Individually, the items purchased by compulsive shoppers tend not to be large or particularly expensive, but many will buy in quantity so that spending gets out of hand. Research has not identified gender-specific buying patterns, but in the author’s experience men tend to have a greater interest than women in electronic, automotive, and hardware goods.

Subjects generally are willing to admit that compulsive buying disorder is problematic. In the study by Christenson and colleagues,14 92% of persons with compulsive buying disorder described attempts to resist urges to buy, although their attempts were often unsuccessful. Subjects indicated that 74% of the time they experienced an urge to buy, the urge resulted in a purchase. Typically, 1–5 hours passed between initially experiencing their urge to buy and the eventual purchase.

Compulsive buying disorder behaviors occur year round, but may be more problematic during the Christmas and other holidays, as well as around the birthdays of family members and friends. Schlosser and colleagues15 reported that subjects show a range of behavior regarding the outcome of a purchase: returning the item, failing to remove the item from the package, selling the item, or even giving it away. Koran and colleagues26 found that compared with other respondents, the person with compulsive buying disorder is more likely to report an income <$50,000, is less likely to pay off credit card balances in full, and gives maladaptive responses regarding his or her consumer behavior. For example, individuals with compulsive buying disorder were more likely to engage in “problem shopping” more frequently and for longer periods, to feel depressed after shopping, to make senseless and impulsive purchases, and to experience uncontrollable buying binges than other respondents.

Compulsive buying occurs along a spectrum of severity. Black and colleagues37 divided a sample of 44 subjects with compulsive buying disorder into quartiles from most to least severe, depending on their CBS score. Greater severity was associated with lower gross income, a lower likelihood of having an income above the median, and spending a lower percentage of income on sale items. Subjects with more severe compulsive buying disorder were also more likely to have Axis I or Axis II comorbidity. These results suggest that the most severe buying disorders are found in psychologically distressed persons with low incomes who have little ability to control or to delay their urges to make inappropriate purchases.

Psychiatric Comorbidity

Data from clinical studies show that persons with compulsive buying disorder frequently meet criteria for Axis I disorders, particularly mood (21% to 100%)38,39 and anxiety (41% to 80%)13,15 disorders, substance use disorders (21% to 46%),14,33 and eating disorders (8% to 35%).13,38 Disorders of impulse control are also relatively common in these individuals (21% to 40%).13,14 The frequency of Axis II disorders in persons with compulsive buying disorder was assessed by Schlosser and colleagues.15 These investigators used both a self-report instrument and a structured interview, and found that nearly 60% of subjects met criteria for at least one personality disorder type through a consensus of both instruments. While there was no special “shopping” personality, the most commonly identified personality disorders were the obsessive-compulsive (22%), avoidant (15%), and borderline (15%) types. Krueger8 observed informally that four patients he treated using psychoanalysis demonstrated aspects of narcissistic character pathology.

Some investigators believe that compulsive buying disorder falls within the obsessive-compulsive spectrum, and point to similarities between compulsive buying disorder and obsessive-compulsive disorder (OCD), including the special symptom of hoarding which involves the acquisition of, and failure to discard, possessions that are of limited use or value.40 Comorbidity studies suggest that from 3%33 to 35%13 of persons with compulsive buying disorder have OCD, yet these studies do not indicate whether the comorbid disorder is based on the presence of concurrent hoarding, or other symptoms, such as compulsive handwashing or cleaning. Clearly, it could be argued that many persons with compulsive buying disorder seem to have a special form of hoarding in which they compulsively acquire new possessions. Yet, unlike the typical hoarder, the items purchased are not inherently valueless or useless.

Family History

There is some evidence that compulsive buying disorder runs in families and that within these families mood, anxiety, and substance use disorders are excessive. McElroy and colleagues13 reported that of 18 individuals with compulsive buying disorder, 17 had one or more first-degree relative with major depression, 11 with alcohol or other substance abuse, and 3 with an anxiety disorder. Three had relatives with compulsive buying disorder. Black and colleagues33 used the family history method to assess 137 first-degree relatives of 31 persons with compulsive buying disorder. Relatives were significantly more likely than those in a comparison group to have depression, alcoholism, a drug use disorder, “any psychiatric disorder,” and “more than one psychiatric disorder.” Compulsive buying disorder was identified in 9.5% of the first- degree relatives, but was not assessed in the comparison group. In molecular genetic studies, Devor and colleagues41 failed to find an association between two serotonin transporter gene polymorphisms and compulsive buying disorder, while Comings and colleagues42 reported an association of compulsive buying disorder with the DRD1 receptor gene.

Etiology

The cause of compulsive buying disorder is unknown, though speculation has settled on developmental, neurobiologic, and cultural influences. Psychoanalysts8-10 have suggested that early life events, such as sexual abuse, are causative factors. Yet, no special or unique family constellation or pattern of early life events has been identified in persons with compulsive buying disorder.

Neurobiologic theories have centered on disturbed neurotransmission, particularly involving the serotonergic, dopaminergic, or opioid systems. Selective serotonin reuptake inhibitors (SSRIs) have been used to treat compulsive buying disorder,34,35,43-45 in part because investigators have noted similarities between compulsive buying disorder and OCD, a disorder known to respond to SSRIs. Dopamine has been theorized to play a role in “reward dependence,” which has been claimed to foster behavioral addictions, such as compulsive buying disorder and pathological gambling.21 Case reports suggesting benefit from the opiate antagonist naltrexone have led to speculation about the role of opiate receptors.46,47 There is currently no direct evidence to support the role of these neurotransmitter systems in the etiology of compulsive buying disorder.

Because compulsive buying disorder occurs mainly in developed countries cultural and social factors have been proposed as either causing, or promoting the disorder.48 Elements which appear necessary for the development of compulsive buying disorder include the presence of a market-based economy, the availability of a wide variety of goods, easily obstained credit, disposable income, and significant leisure time.19 For these reasons, compulsive buying disorder is unlikely to occur in poorly developed countries except among the wealthy elite.

Assessment

The goal of assessment is to define the problem through inquiries regarding the person’s attitudes about shopping and spending, and their specific shopping behaviors and patterns.49 Typical inquiries might include: “Do you feel overly preoccupied with shopping and spending?” “Do you ever feel that your shopping behavior is excessive, inappropriate or uncontrolled?” “Have your shopping desires, urges, fantasies, or behaviors ever been overly time consuming, caused you to feel upset or guilty, or lead to serious problems in your life such as financial or legal problems or loss of a relationship?” Clinicians should take note of past psychiatric treatment, including medications, hospitalizations, and psychotherapy. A history of physical illness, surgical procedures, drug allergies, or medical treatment is important to note because it may help rule out medical explanations as a cause of the compulsive buying disorder (eg, neurological disorders, brain tumors). Bipolar disorder needs to be ruled out as a cause of the excessive shopping and spending. Typically, the manic patient’s unrestrained spending corresponds to manic episodes, and is accompanied by euphoric mood, grandiosity, unrealistic plans, and often a giddy, overly bright affect. The pattern of shopping and spending in the person with compulsive buying disorder lacks the periodicity seen with bipolar patients, and suggests an ongoing preoccupation.50 

Compulsive buying disorder also needs to be distinguished from normal buying behavior, although the distinctions are sometimes arbitrary. In the United States and other developed countries, shopping is a major pastime, particularly for women, and frequent shopping in and of itself does not constitute evidence in support of a diagnosis of compulsive buying disorder. Normal buying can also sometimes take on a compulsive quality, particularly around special holidays or birthdays. Individuals who receive an inheritance or win a lottery may experience shopping sprees as well.

Several instruments have been developed to either identify compulsive buying disorder or rate its severity. The CBS, which seems to reliably distinguish normal from pathological buyers, consists of seven items representing specific behaviors, motivations, and feelings associated with compulsive buying disorder.24 Edwards51 has developed a useful 13-item scale that assesses important experiences and feelings about shopping and spending. Monahan and colleagues52 modified the Yale Brown Obsessive-Compulsive Scale to create theYale Brown Obsessive-Compulsive Scale-Shopping Version. The 10-item scale rates time involved, interference, distress, resistance, and degree of control for both cognitions, and behaviors typical of compulsive buying disorder, yielding a score ranging from 0–40. Monahan and colleagues52 showed that the scale had good inter-rater reliability and was valid in measuring both severity and change during a clinical trial. In their study, participants with compulsive buying disorder had a mean score of 21 (range: 18–25) compared with a score of 4 (range: 1–7) for normal buyers.

The Minnesota Impulsive Disorders Interview is a semi-structured interview developed by Christenson and colleagues14 to assess the presence of compulsive buying disorder, kleptomania, trichotillomania, intermittent explosive disorder, compulsive sexual behavior, pathological gambling, and compulsive exercise. These investigators have also developed an expanded 82-item module for those screening positive for compulsive buying disorder. Grant and colleagues29 found that the instrument had a sensitivity of 100% and a specificity of 96.2% for compulsive buying disorder when comparing the instrument to the criteria of McElroy and colleagues.13 The instrument will mainly be of interest to researchers.

Treatment

There is no standard treatment for compulsive buying disorder. Recent work has focused on the use of psychotropic medication to treat compulsive buying disorder, and in developing cognitive-behavioral therapy models, the most successful involving the use of a group treatment. The first use of group therapy was described by Damon,53 and later models were developed by Burgard and Mitchell,54 Villarino and colleagues,55 and, more recently, by Benson and Gengler.56 Mitchell and colleagues36 found that group cognitive-behavioral therapy produced significant improvement compared with a wait list in a 12-week pilot study. In this study, 28 subjects were assigned to receive active treatment and 11 to the waiting-list control condition. Improvement was maintained during a 6-month follow-up. Benson57 has recently developed a comprehensive self-help program which combines cognitive-behavioral strategies with self-monitoring. A detailed workbook, a shopping diary, and a CD-ROM are included.

Self-help books are available (ie, bibliotherapy),58-60 and some persons with compulsive buying disorder may also benefit from attending Debtors Anonymous, a support group patterned after Alcoholics Anonymous. Simplicity circles have been started in some US cities. In these groups, people are encouraged to adopt a simple lifestyle, and to abandon their compulsive buying disorder.61 Many subjects with compulsive buying disorder develop substantial financial problems, and may benefit from visiting a financial counselor.62 The author has seen cases in which a financial conservator appointed to control the patient’s finances has been helpful. While a conservator controls the patient’s spending, this approach does not reverse the individual’s preoccupation with shopping. Marital (or couples) therapy may also be helpful, particularly when compulsive buying disorder in one member of the dyad has disrupted the relationship.63

Medication treatment studies have produced mixed results. An early report on three cases suggested that antidepressants could curb compulsive buying disorder,64 and was followed by a more detailed report13 on 20 cases, nine of whom experienced full or partial remission to trials of antidepressants, most often SSRIs, sometimes in combination with a mood stabilizer. In most cases, the observation period was limited to a few weeks or months. Black and colleagues43 reported in an early open-label trial that 9 of 10 non-depressed subjects with compulsive buying disorder given fluvoxamine showed benefit. Two subsequent randomized controlled trials34,44 found that fluvoxamine did no better than placebo. Black and colleagues44 randomized 12 subjects with compulsive buying disorder to fluvoxamine and 11 to placebo. At the conclusion of the trial, 50% of fluvoxamine recipients and 64% of placebo recipients were rated as responders. Subjects in both treatment cells showed improvement as early as the second week of the 9-week study. Likewise, Ninan and colleagues34 reported that in a 12-week two-site trial in which 20 subjects received fluvoxamine and 17 received placebo, that the intent-to-treat analysis failed to show a significant difference between the groups. In another open-label trial,38 citalopram produced substantial improvement in 24 subjects with compulsive buying disorder; responders to citalopram were then enrolled in a 9-week randomized, placebo-controlled trial.35 Compulsive shopping symptoms returned in five of eight subjects assigned to placebo compared with none of the seven who continued taking citalopram. By comparison, escitalopram showed little effect for compulsive buying disorder in an identically designed discontinuation trial by the same investigators.45 In this study, 17 of 26 women who were considered responders in an initial open-label phase of the study, were randomized to further treatment with escitalopram or placebo. At the end of the 9-week study, there was no significant difference in relapse rates with the treatment groups. Grant46 and Kim47 have described cases in which persons with compulsive buying disorder have improved with naltrexone, suggesting that opiate antagonists may play a role in the treatment of compulsive buying disorder. Interpretation of treatment studies is complicated by placebo response rates as high as 64%.44

Conclusion

Interest in compulsive buying disorder has greatly expanded in the past decade leading to a greater understanding of its epidemiology, phenomenology, family history, and treatment. The disorder is relatively common, is associated with important comorbid psychiatric disorders, and can lead to serious impairment in personal and social functioning, and can lead directly to financial problems and legal entanglements. Yet, more work needs to be done if we are to fully understand the disorder. First, although several definitions have been proposed, most prominently the criteria of McElroy and colleagues,13 their reliability and validity have yet to be established. And, although the Minnesota Impulsive Disorders Interview14 shows promise as a diagnostic tool, its psychometric properties need further study. While it seems that the disorder is chronic or intermittent, at least one study31 shows that the course may be modified with treatment. Follow-up studies would be helpful in charting the course of the disorder, tracking its emergence or subsidence, and its relationship to other psychiatric disorders (eg, Does major depression precede or follow the emergence of compulsive buying disorder?).

The issue of gender differences is unsettled; the recent study by Koran and colleagues26 suggested that the disorder affects men and women equally, yet this conclusion conflicts with other surveys, as well as most clinically based data. Also, the issue of whether compulsive buying disorder represents a single construct or has multiple subtypes suggesting alternate etiologies or pathophysiologies has not been studied. Some investigators suggest that the disorder is related to OCD, yet others suggest that it is related to the substance use disorders, or to the mood disorders. Perhaps compulsive buying disorder is best considered a disorder of impulse control. It could be that all investigators are correct in that subgroups of compulsive buyers are motivated by different underlying diatheses that correspond to these different diagnostic criteria. Neurobiological studies employing various brain imaging techniques may be one way to clarify these connections. Finally, treatment studies have suggested that compulsive buying disorder may respond to cognitive-behavioral strategies. Yet, it is not clear which patients do best with this treatment, or whether the improvement persists. Medication studies are hampered by high placebo response rates, a feature that needs to be considered in planning future studies. It could be that different subgroups of patients will preferentially respond to particular types of drugs reflecting their underlying neurobiology.

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