A review of compulsive buying disorder (2024)

Abstract

Compulsive buying disorder (CBD) is characterized by excessive shoppingcognitions and buying behavior that leads to distress or impairment. Foundworldwide, the disorder has a lifetime prevalence of 5.8% in the US generalpopulation. Most subjects studied clinically are women (~80%), though thisgender difference may be artifactual. Subjects with CBD report a preoccupationwith shopping, prepurchase tension or anxiety, and a sense of relief followingthe 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 appearto meet criteria for an Axis II disorder, although there is no special "shopping"personality. Compulsive shopping tends to run in families, and these familiesare filled with mood and substance use disorders. There are no standard treatments.Psychopharmacologic treatment studies are being actively pursued, and groupcognitive-behavioral models have been developed and are promising. DebtorsAnonymous, simplicity circles, bibliotherapy, financial counseling, and maritaltherapy may also play a role in the management of CBD.

Keywords: Compulsive shopping, compulsive buying, impulse control disorders

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

CBD attracted little attention throughout the 20th century except amongconsumer 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 researchershave 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 otherwisespecified". Research criteria have been developed that emphasize its cognitiveand behavioral aspects (10). Some writershave criticized attempts to categorize CBD as an illness, which they see aspart of a trend to "medicalize" behavioral problems (20). Yet, this approach ignores the reality of CBD, and bothtrivializes and stigmatizes attempts to understand or treat the disorder.

EPIDEMIOLOGY

Koran et al (21) recently estimatedthe point prevalence of CBD to be 5.8% of respondents, based on results froma random telephone survey of 2,513 adults conducted in the US. Earlier, Faberand O'Guinn (22) had estimated theprevalence 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 reportedfigures ranging from 12% to 16% (24,25). There is no evidence that CBD has increasedin prevalence in the past few decades.

Community based and clinical surveys suggest that 80% to 95% of personswith CBD are women (10-12,23). The reportedgender difference could be artifactual: women readily acknowledge that theyenjoy shopping, whereas men are more likely to report that they "collect".The report of Koran et al (21) suggeststhat this may be the case: in their survey, a near equal percentage of menand women met criteria for CBD (5.5% and 6.0%, respectively). However, Dittmar(26) concluded from a general populationsurvey in the United Kingdom, in which 92% of respondents considered compulsiveshoppers were women, that the gender difference is real and is not an artifactof 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 thatthe age of onset corresponds with emancipation from the home, and the ageat which people first establish credit accounts.

There are no careful longitudinal studies of CBD, but the majority of subjectsstudied by Schlosser et al (12) andMcElroy et al (10) describe their courseas continuous. Aboujaoude et al (28)suggested that persons with CBD who responded to treatment with citalopramwere likely to remain in remission during one-year follow-up, a finding thatsuggests that treatment could alter the natural history of the disorder. Theauthors' personal observation is that subjects with CBD typically report decadesof compulsive shopping behavior at the time of presentation, although it mightbe argued that clinical samples are biased in favor of severity.

There is some evidence that CBD runs in families and that within thesefamilies mood, anxiety, and substance use disorders are excessive. McElroyet al (8) reported that, of 18 individualswith 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 havedepression, alcoholism, a drug use disorder, "any" psychiatric disorder, and"more than one psychiatric disorder". CBD was identified in 9.5% of the FDRsof the CBD probands (CBD was not assessed in the comparison group). In moleculargenetic studies, Devor et al (30) failedto find an association between two serotonin transporter gene polymorphismsand CBD, while Comings (31) reportedan association of CBD with the DRD1 receptor gene.

CLINICAL SYMPTOMS

Persons with CBD are preoccupied with shopping and spending, and devotesignificant time to these behaviors. While it might be argued that a personcould be a compulsive shopper and not spend, and confine his or her interestto window shopping, this pattern is uncommon. The author's personal observationis that the two aspects - shopping and spending - are intertwined. Personswith CBD often describe an increasing level of urge or anxiety that can onlylead 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 personwith CBD develops thoughts, urges, or preoccupations with either having aspecific item, or with the act of shopping. In the second phase, the personprepares for shopping and spending. This can include decisions on when andwhere to go, on how to dress, and even which credit cards to use. Considerableresearch may have taken place about sale items, new fashions, or new shops.The third phase involves the actual shopping experience, which many individualswith CBD describe as intensely exciting, and can even lead to a sexual feeling(12). Finally, the act is completedwith a purchase, often followed by a sense of let down, or disappointmentwith oneself (21). In a study of theantecedents 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 antecedentsto CBD, while euphoria or relief from the negative emotions were the mostcommon consequence.

Individuals with CBD tend to shop by themselves, although some will shopwith friends who may share their interest in shopping (11,12). In general,CBD is a private pleasure which could lead to embarrassment if someone notsimilarly interested in shopping accompanied them. Shopping may occur in justabout any venue, ranging from high fashion department stores and boutiquesto consignment shops or garage sales. Income has relatively little to do withthe existence of CBD: persons with a low income can still be fully preoccupiedby shopping and spending, although their level of income will lead them toshop 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 bycompulsive shoppers tend not to be particularly expensive, but the authorhas observed that many compulsive shoppers buy in quantity resulting in outof control spending. Anecdotally, patients often report buying a product basedon its attractiveness or because it was a bargain. In the study by Christensonet al (11), compulsive shoppers reportedspending 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, inthe author's experience men tend to have a greater interest than women inelectronic, automotive, or hardware goods. Like women, they are also interestedin clothing, shoes, and compact discs.

Subjects generally are willing to acknowledge that CBD is problematic.Schlosser et al (10) reported that85% of their subjects expressed concern with their CBD-related debts, andthat 74% felt out of control while shopping. In the study by Miltenbergeret al (32), 68% of persons with CBDreported that it negatively affected their relationships. Christenson et al(11) reported that nearly all of theirsubjects (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 duringthe Christmas or other important holidays, and around the birthdays of familymembers and friends (12). Schlosseret al (12) found that subjects reporteda range of behaviors regarding the outcome of a purchase, including returningthe 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 lowergross income, less likelihood of having an income above the median, and spendinga lower percentage of income on sale items. Subjects with more severe CBDwere also more likely to have comorbid Axis I or Axis II disorders. Thesedata suggest that the most severe forms of CBD are found in persons with lowincomes who have little ability to control or to delay their urge to makeimpulsive purchases.

PSYCHIATRIC COMORBIDITY

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

Schlosser et al (12) found thatnearly 60% of subjects with CBD met criteria for at least one Axis II disorder.While there was no special "shopping" personality, the most frequently identifiedpersonality 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 ofnarcissistic character pathology.

ETIOLOGY

The etiology of CBD is unknown, though speculation has settled on developmental,neurobiological, and cultural influences. Psychoanalysts (7-9) have suggestedthat early life events, such as sexual abuse, are causative factors. Yet,no special or unique family constellation or pattern of early life eventshas 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 notedsimilarities between CBD and obsessive-compulsive disorder, a disorder knownto respond to SSRIs. Dopamine has been theorized to play a role in "rewarddependence", which has been claimed to foster "behavioral addictions" (e.g.,CBD, pathological gambling) (39). Casereports suggesting benefit from the opiate antagonist naltrexone have ledto speculation about the role of opiate receptors (40,41). There is currently no direct evidenceto support the role of these neurotransmitter systems in the etiology of CBD.

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

ASSESSMENT

The goal of assessment is to identify CBD through inquiries regarding theperson's attitudes and behaviors towards shopping and spending (43). Inquiries might include: "Do you feel overly preoccupiedwith shopping and spending?"; "Do you ever feel that your shopping behavioris excessive, inappropriate or uncontrolled?"; "Have your shopping desires,urges, fantasies, or behaviors ever been overly time consuming, caused youto feel upset or guilty, or lead to serious problems in your life such asfinancial 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, surgicalprocedures, drug allergies, or medical treatment is important to note, becauseit may help rule out medical explanations as a cause of the CBD (e.g., neurologicaldisorders, brain tumors). Bipolar disorder needs to be ruled out as a causeof the excessive shopping and spending. Typically, the manic patient's unrestrainedspending corresponds to manic episodes, and is accompanied by euphoric mood,grandiosity, unrealistic plans, and often a giddy, expansive affect. The patternof shopping and spending in the person with CBD lacks the periodicity seenwith bipolar patients, and suggests an ongoing preoccupation.

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

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

TREATMENT

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

Interest in CBT has largely replaced earlier interest in psychodynamictherapies. Several competing CBT models have been developed, the most successfulinvolving the use of group treatment (46-49). The first use of group therapy was describedby Damon (46). Subsequent group modelswere developed by Burgard and Mitchell (47),Villarino et al (48), and more recentlyby Benson and Gengler (49). Mitchellet al (50) reported that their groupCBT model produced significant improvement compared to a wait list in a 12-weekpilot study; improvement was maintained during a 6-months follow-up. Benson(51) has recently developed a comprehensiveself-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 behelpful to some persons with CBD. Debtors Anonymous, patterned after AlcoholicsAnonymous, is a voluntary, lay-run group that provides an atmosphere of mutualsupport and encouragement for those with substantial debts. Simplicity circlesare available in some US cities; these voluntary groups encourage people toadopt a simple lifestyle, and to abandon their CBD (55). Many subjects with CBD develop substantial financialproblems, and may benefit from financial counseling (56). The author has seen cases in which a financial conservatorhas been appointed to control the patient's finances, and appears to havehelped. While a conservator controls the person's spending, this approachdoes not reverse his or her preoccupation with shopping and spending. Marriage(or couples) counseling may be helpful, particularly when CBD in one memberof the dyad has disrupted the relationship (57).

Psychopharmacologic treatment studies have yielded mixed results. An earlycase series suggested that antidepressants could curb CBD (58), and an early open-label trial using fluvoxamine showedbenefit (34). Yet, two subsequent randomizedcontrolled trials found that fluvoxamine did no better than placebo (35,36).In another open-label trial (28), citalopramproduced substantial improvement. In this particular study, responders toopen-label citalopram were then enrolled in a nine-week randomized placebocontrolled trial (38). Compulsive shoppingsymptoms returned in five of eight subjects assigned to placebo compared withnone of the seven who continued taking citalopram. By comparison, escitalopramshowed little effect for CBD in an identically designed discontinuation trialby the same investigators (39). Grant(40) and Kim (41) have described cases in which persons with CBD improvedwith naltrexone, suggesting that opiate antagonists might play a role in thetreatment of CBD. Interpretation of treatment studies is complicated by thehigh placebo response rate associated with CBD (ranging to 64%) (35).

The author has developed a set of recommendations (59). First, pharmacologic treatment trials provide littleguidance, and patients should be informed that they cannot rely on medication.Further, patients should: a) admit that they have CBD; b) get rid of creditcards and checkbooks, because they are easy sources of funds that fuel thedisorder; c) shop with a friend or relative; the presence of a person withoutCBD will help curb the tendency to overspend; and d) find meaningful waysto spend one's leisure time other than shopping.

References