A review of compulsive buying disorder

Abstract

Compulsive buying disorder (CBD) is characterized by excessive shopping cognitions and buying behavior that leads to distress or impairment. Found worldwide, the disorder has a lifetime prevalence of 5.8% in the US general population. Most subjects studied clinically are women (~80%), though this gender difference may be artifactual. Subjects with CBD report a preoccupation with shopping, prepurchase tension or anxiety, and a sense of relief following the purchase. CBD is associated with significant psychiatric comorbidity, particularly mood and anxiety disorders, substance use disorders, eating disorders, and other disorders of impulse control. The majority of persons with CBD appear to meet criteria for an Axis II disorder, although there is no special "shopping" personality. Compulsive shopping tends to run in families, and these families are filled with mood and substance use disorders. There are no standard treatments. Psychopharmacologic treatment studies are being actively pursued, and group cognitive-behavioral models have been developed and are promising. Debtors Anonymous, simplicity circles, bibliotherapy, financial counseling, and marital therapy may also play a role in the management of CBD.

Compulsive buying disorder (CBD) was first described clinically in the early 20th century by Bleuler (1) and Kraepelin (2), both of whom included CBD in their textbooks. Bleuler writes: "As a last category Kraepelin mentions the buying maniacs (oniomaniacs) in whom even buying is compulsive and leads to senseless contraction of debts with continuous delay of payment until a catastrophe clears the situation a little - a little bit never altogether because they never admit to their debts" (1). Bleuler described CBD as an example of a "reactive impulse", or "impulsive insanity", which he grouped alongside kleptomania and pyromania.

CBD attracted little attention throughout the 20th century except among consumer behaviorists (3-6) and psychoanalysts (7-9). Interest was revived in the early 1990s, when clinical case series from three independent research groups appeared (10-12). The disorder has been described worldwide, with reports coming from the US (10-12), Canada (5), England (4), Germany (6), France (13), and Brazil (14).

The appropriate classification of CBD continues to be debated. Some researchers have linked CBD to addictive disorders (15), while others have linked it to obsessive-compulsive disorder (16), and still others to mood disorders (17). While not included in DSM-IV (18), CBD was included in DSM-III-R (19) as an example of an "impulsecontrol disorder not otherwise specified". Research criteria have been developed that emphasize its cognitive and behavioral aspects (10). Some writers have criticized attempts to categorize CBD as an illness, which they see as part of a trend to "medicalize" behavioral problems (20). Yet, this approach ignores the reality of CBD, and both trivializes and stigmatizes attempts to understand or treat the disorder.

EPIDEMIOLOGY

Koran et al (21) recently estimated the point prevalence of CBD to be 5.8% of respondents, based on results from a random telephone survey of 2,513 adults conducted in the US. Earlier, Faber and O'Guinn (22) had estimated the prevalence of CBD to fall between 2% and 8% of the general population of Illinois. Both research groups had used the Compulsive Buying Scale (CBS) (23) to identify compulsive buyers. Other surveys have reported figures ranging from 12% to 16% (24,25). There is no evidence that CBD has increased in prevalence in the past few decades.

Community based and clinical surveys suggest that 80% to 95% of persons with CBD are women (10-12,23). The reported gender difference could be artifactual: women readily acknowledge that they enjoy shopping, whereas men are more likely to report that they "collect". The report of Koran et al (21) suggests that this may be the case: in their survey, a near equal percentage of men and women met criteria for CBD (5.5% and 6.0%, respectively). However, Dittmar (26) concluded from a general population survey in the United Kingdom, in which 92% of respondents considered compulsive shoppers were women, that the gender difference is real and is not an artifact of men being underrepresented in samples.

The age of onset of CBD appears to be in the late teens or early twenties (11,12,27), though McElroy et al (10) reported a mean age at onset of 30 years. It may be that the age of onset corresponds with emancipation from the home, and the age at which people first establish credit accounts.

There are no careful longitudinal studies of CBD, but the majority of subjects studied by Schlosser et al (12) and McElroy et al (10) describe their course as continuous. Aboujaoude et al (28) suggested that persons with CBD who responded to treatment with citalopram were likely to remain in remission during one-year follow-up, a finding that suggests that treatment could alter the natural history of the disorder. The authors' personal observation is that subjects with CBD typically report decades of compulsive shopping behavior at the time of presentation, although it might be argued that clinical samples are biased in favor of severity.

There is some evidence that CBD runs in families and that within these families mood, anxiety, and substance use disorders are excessive. McElroy et al (8) reported that, of 18 individuals with CBD, 17 had one or more first-degree relatives (FDRs) with major depression, 11 with an alcohol or drug use disorder, and three with an anxiety disorder. Three had relatives with CBD. Black et al (29) used the family history method to assess 137 FDRs of 33 persons with CBD. FDRs 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". CBD was identified in 9.5% of the FDRs of the CBD probands (CBD was not assessed in the comparison group). In molecular genetic studies, Devor et al (30) failed to find an association between two serotonin transporter gene polymorphisms and CBD, while Comings (31) reported an association of CBD with the DRD1 receptor gene.

CLINICAL SYMPTOMS

Persons with CBD are preoccupied with shopping and spending, and devote significant time to these behaviors. While it might be argued that a person could be a compulsive shopper and not spend, and confine his or her interest to window shopping, this pattern is uncommon. The author's personal observation is that the two aspects - shopping and spending - are intertwined. Persons with CBD often describe an increasing level of urge or anxiety that can only lead to a sense of completion when a purchase is made.

The author has been able to identify four distinct phases of CBD: 1) anticipation; 2) preparation; 3) shopping; and 4) spending. In the first phase, the person with CBD develops thoughts, urges, or preoccupations with either having a specific item, or with the act of shopping. In the second phase, the person prepares for shopping and spending. This can include decisions on when and where to go, on how to dress, and even which credit cards to use. Considerable research may have taken place about sale items, new fashions, or new shops. The third phase involves the actual shopping experience, which many individuals with CBD describe as intensely exciting, and can even lead to a sexual feeling (12). Finally, the act is completed with a purchase, often followed by a sense of let down, or disappointment with oneself (21). In a study of the antecedents and consequences of CBD, Miltenberger et al (32) reported that negative emotions (e.g., depression, anxiety, boredom, self-critical thoughts, anger) were the most commonly cited antecedents to CBD, while euphoria or relief from the negative emotions were the most common consequence.

Individuals with CBD tend to shop by themselves, although some will shop with friends who may share their interest in shopping (11,12). In general, CBD is a private pleasure which could lead to embarrassment if someone not similarly interested in shopping accompanied them. Shopping may occur in just about any venue, ranging from high fashion department stores and boutiques to consignment shops or garage sales. Income has relatively little to do with the existence of CBD: persons with a low income can still be fully preoccupied by shopping and spending, although their level of income will lead them to shop at a consignment shop rather than a department store.

Typical items purchased by persons with CBD include (in descending order) clothing, shoes, compact discs, jewelry, cosmetics, and household items (11,12,32). Individually, the items purchased by compulsive shoppers tend not to be particularly expensive, but the author has observed that many compulsive shoppers buy in quantity resulting in out of control spending. Anecdotally, patients often report buying a product based on its attractiveness or because it was a bargain. In the study by Christenson et al (11), compulsive shoppers reported spending an average of $110 during a typical shopping episode compared with $92 reported in the study by Schlosser et al (12).

Although research has not identified gender specific buying patterns, in the author's experience men tend to have a greater interest than women in electronic, automotive, or hardware goods. Like women, they are also interested in clothing, shoes, and compact discs.

Subjects generally are willing to acknowledge that CBD is problematic. Schlosser et al (10) reported that 85% of their subjects expressed concern with their CBD-related debts, and that 74% felt out of control while shopping. In the study by Miltenberger et al (32), 68% of persons with CBD reported that it negatively affected their relationships. Christenson et al (11) reported that nearly all of their subjects (92%) tried to resist their urges to buy, but were rarely successful. The subjects indicated that 74% of the time they experienced an urge to buy, the urge resulted in a purchase.

CBD tends to occur year round, although it may be more problematic during the Christmas or other important holidays, and around the birthdays of family members and friends (12). Schlosser et al (12) found that subjects reported a range of behaviors regarding the outcome of a purchase, including returning the item, failing to remove the item from the packaging, selling the item, or even giving it away.

In a study of 44 subjects with CBD, Black et al (33) reported that greater severity was associated with lower gross income, less likelihood of having an income above the median, and spending a lower percentage of income on sale items. Subjects with more severe CBD were also more likely to have comorbid Axis I or Axis II disorders. These data suggest that the most severe forms of CBD are found in persons with low incomes who have little ability to control or to delay their urge to make impulsive purchases.

PSYCHIATRIC COMORBIDITY

Persons with CBD frequently meet criteria for Axis I disorders, particularly mood disorders (21-100%) (27,34), anxiety disorders (41-80%) (10,12), substance use disorders (21-46%) (11,29), and eating disorders (8-35%) (10,27). Disorders of impulse control are also relatively common in these individuals (21-40%) (10,11).

Schlosser et al (12) found that nearly 60% of subjects with CBD met criteria for at least one Axis II disorder. While there was no special "shopping" personality, the most frequently identified personality disorders were the obsessive-compulsive (22%), avoidant (15%), and borderline (15%) types. Krueger (7), a psychoanalyst, described four patients who he observed to have aspects of narcissistic character pathology.

ETIOLOGY

The etiology of CBD is unknown, though speculation has settled on developmental, neurobiological, and cultural influences. Psychoanalysts (7-9) 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 CBD.

Neurobiological theories have centered on disturbed neurotransmission, particularly involving the serotonergic, dopaminergic, or opioid systems. Selective serotonin reuptake inhibitors (SSRIs) have been used to treat CBD (27,34- 38), in part because investigators have noted similarities between CBD and obsessive-compulsive disorder, 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" (e.g., CBD, pathological gambling) (39). Case reports suggesting benefit from the opiate antagonist naltrexone have led to speculation about the role of opiate receptors (40,41). There is currently no direct evidence to support the role of these neurotransmitter systems in the etiology of CBD.

Cultural mechanisms have been proposed to recognize the fact that CBD occurs mainly in developed countries (42). Elements which appear necessary for the development of CBD include the presence of a market-based economy, the availability of a wide variety of goods, disposable income, and significant leisure time. For these reasons, CBD is unlikely to occur in poorly developed countries, except among the wealthy elite (Imelda Marcos and her many shoes come to mind).

ASSESSMENT

The goal of assessment is to identify CBD through inquiries regarding the person's attitudes and behaviors towards shopping and spending (43). 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 the loss of a relationship?".

Clinicians should note 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 CBD (e.g., 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, expansive affect. The pattern of shopping and spending in the person with CBD lacks the periodicity seen with bipolar patients, and suggests an ongoing preoccupation.

Normal buying behavior should also be ruled out. In the US and other developed countries, shopping is a major pastime, particularly for women, and frequent shopping does not necessarily constitute evidence in support of a diagnosis of CBD. Normal buying can sometimes take on a compulsive quality, particularly around special holidays or birthdays. Persons who receive an inheritance or win a lottery may experience shopping sprees as well.

Several instruments have been developed to either identify CBD or rate its severity. The CBS (23), already mentioned, consists of seven items representing specific behaviors, motivations, and feelings associated with compulsive buying, and reliably distinguishes normal buyers from those with CBD. Edwards (44) has developed a useful 13-item scale that assesses important experiences and feelings about shopping and spending. Monahan et al (45) modified the Yale Brown Obsessive-Compulsive Scale to create the YBOCS-Shopping Version (YBOCS-SV) to assess cognitions and behaviors associated with CBD. This 10-item scale rates time involved, interference, distress, resistance, and degree of control for both cognitions and behaviors. The instrument is designed to measure severity of CBD, and change during clinical trials.

TREATMENT

There are no evidence-based treatments for CBD. In recent years, treatment studies of CBD have focused on the use of psychotropic medication (mainly antidepressants) and cognitive-behavioral therapy (CBT).

Interest in CBT has largely replaced earlier interest in psychodynamic therapies. Several competing CBT models have been developed, the most successful involving the use of group treatment (46-49). The first use of group therapy was described by Damon (46). Subsequent group models were developed by Burgard and Mitchell (47), Villarino et al (48), and more recently by Benson and Gengler (49). Mitchell et al (50) reported that their group CBT model produced significant improvement compared to a wait list in a 12-week pilot study; improvement was maintained during a 6-months follow-up. Benson (51) 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.

Several self-help books (bibliotherapy) are available (52- 54), and may be helpful to some persons with CBD. Debtors Anonymous, patterned after Alcoholics Anonymous, is a voluntary, lay-run group that provides an atmosphere of mutual support and encouragement for those with substantial debts. Simplicity circles are available in some US cities; these voluntary groups encourage people to adopt a simple lifestyle, and to abandon their CBD (55). Many subjects with CBD develop substantial financial problems, and may benefit from financial counseling (56). The author has seen cases in which a financial conservator has been appointed to control the patient's finances, and appears to have helped. While a conservator controls the person's spending, this approach does not reverse his or her preoccupation with shopping and spending. Marriage (or couples) counseling may be helpful, particularly when CBD in one member of the dyad has disrupted the relationship (57).

Psychopharmacologic treatment studies have yielded mixed results. An early case series suggested that antidepressants could curb CBD (58), and an early open-label trial using fluvoxamine showed benefit (34). Yet, two subsequent randomized controlled trials found that fluvoxamine did no better than placebo (35,36). In another open-label trial (28), citalopram produced substantial improvement. In this particular study, responders to open-label citalopram were then enrolled in a nine-week randomized placebo controlled trial (38). 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 CBD in an identically designed discontinuation trial by the same investigators (39). Grant (40) and Kim (41) have described cases in which persons with CBD improved with naltrexone, suggesting that opiate antagonists might play a role in the treatment of CBD. Interpretation of treatment studies is complicated by the high placebo response rate associated with CBD (ranging to 64%) (35).

The author has developed a set of recommendations (59). First, pharmacologic treatment trials provide little guidance, and patients should be informed that they cannot rely on medication. Further, patients should: a) admit that they have CBD; b) get rid of credit cards and checkbooks, because they are easy sources of funds that fuel the disorder; c) shop with a friend or relative; the presence of a person without CBD will help curb the tendency to overspend; and d) find meaningful ways to spend one's leisure time other than shopping.