#
2002 Martin Dunitz Ltd
International Journal of Psychiatry in Clinical Practice 2002 Volume 6 Pages 65 ± 68
65
Impulsive behavior in a consumer culture HEIDI J HARTSTON AND LORRIN M KORAN
Int J Psych Clin Pract Downloaded from informahealthcare.com by University of California Irvine on 11/07/14 For personal use only.
Department of Psychiatry and Behavioral Sciences, Stanford University Medical Center, Stanford, CA 94305-5721, USA
Correspondence Address Heidi Hartston PhD, Obsessive Compulsive Disorder Clinic, 401 Quarry Road MC 5721, Stanford, CA 94305, USA Tel: (650) 723-8212 Fax: (650) 725-0363 E-mail: [email protected]
Received 16 May 2001; revised 2 January 2002; accepted for publication 9 January 2002
Compulsive shopping behaviour has recently received long overdue attention as a clinical issue. Curiosity about this condition has led to questions about its identification, characterization as a disorder, and treatment. INTRODUCTION:
This article presents two case vignettes illustrating diagnosti c criteria and points that distinguish this disorder from OCD hoarding or mania. These issues are discussed. METHOD:
RESULTS:
The authors present some suggested treatment approaches .
Greater awareness of the prevalence and social consequences of compulsive shopping behaviour highlights the need for treatment and for educational resources for clinicians and the general public. (Int J Psych Clin Pract 2002; 6: 65 ± 68) CONCLUSION:
Keywords compulsive shopping impulse control disorders compulsive
INTRODUCTION
R
esearchers into consumerism and researchers into mental health have become more aware of common scenarios involving `out of control’ buying behavior associated with substantial financial, marital, occupational, social and psychological consequences. In its more severe form, `compulsive shopping’, or `pathological buying’ falls within the DSM-IV category of `impulse control disorders not otherwise specified’. Whether compulsive shopping is best characterized as an obsessive ± compulsive spectrum disorder, impulse control disorder, or a behavioral reaction to major depression or another primary psychiatric disorder, remains uncertain. Descriptive papers1 ± 10 provide general descriptions and information about the demographic s and frequenc y of this behavioral problem, and case studies such as those presented in this paper can help shed more light on the underlyin g psychologica l issues and the often devastating consequence s of the behavior, and can help in guiding treatment. We also include a section on medication and psychotherapy treatments, describing empirically based approaches which are currently being explored. Compulsive shopping behavior may affect 2 ± 8% of the US population, depending on the criteria used, and appears to have a gender ratio of 9 : 1 (female to male).11 Diagnostic criteria for compulsive shopping, outlined by
pathologica l buying impulsive
McElroy et al,3 include: 1. frequent preoccupation with shopping or intrusive, irresistible , `senseless ’ buying impulses; 2. clearly buying more than is needed or can be afforded; 3. distress related to buying behavior; and 4. significan t interferenc e with work or social functioning . These criteria are consistent with those used to diagnose other impulse control disorders such as pathological gambling, kleptomania and trichotilloman ia. The phenomenology of the disorder is also similar to that of other impulse control disorders in that patients report preoccupation with buying and a preceding sense of tension, focused either on the purchase of a particular item, or on buying in general, which is relieved by the act of buying. Feelings of power, pleasure, happiness, relief or emotional numbness accompany the act of buying, and an array of consequence s follows. The frequency of problematic compulsive shopping episodes can range from once a month to once a day and the amount spent per episode varies widely, depending on availabl e funds, methods of payment (credit cards versus cash) and the type of objects typically purchased. Common items which are compulsively purchased include clothes, make-up, art, jewelry, computer equipment, books, and craft or gardening supplies. Many compulsive shoppers compare their experience to an addiction, describing time-consumi ng preoccupation, failure to fulfill major role obligations at home or work due to shopping or thinking about it, and
Int J Psych Clin Pract Downloaded from informahealthcare.com by University of California Irvine on 11/07/14 For personal use only.
66
HJ Hartston and LM Koran
recurrent problematic behavior despite legal consequence s (such as bankruptcy), social difficultie s (negative feedback from friends, family, isolation) and/or interpersona l problems (marital conflict, divorce). After a brief media announcemen t of a compulsive shopping study, our clinic received more than 200 calls from individual s reporting trouble with compulsive shopping behavior, requesting information and treatment. Publicizin g informatio n about compulsive shopping behavior may aid in the recognition of such behavior, and bring individual s out from the secrecy and shame that often accompanie s mental health issues. The following case descriptions exemplify many common features of compulsive shopping behavior. Both patients participated in a brief cognitive-be havioral group psychotherap y treatment trial for compulsive shopping (Hartston and Koran, unpublished ) and both made substantial improvement s in understandi ng and managing their shopping behavior.
CASE 1 Mrs A, a 56-year-old college professor, first sought treatment for her shopping behavior after spending years recovering from a bankruptcy and again incurring significan t debt beyond her ability to pay. She described having had difficult y with uncontrolled buying since her early twenties, when she first began to manage her own money. In her 20s and 30s, she underwent psychotherap y to address a history of child abuse, and again in her 40s to address bereavement issues after the loss of her last parent. Her spending became notably worse after receiving her inheritance, and the buying behavior continued, reportedly ``wrecking my life’’. She described her marriage as happy until financial difficultie s resulting from her shopping threatened the living situation and lifestyle of the couple and became a focus of dispute. As her shopping behavior worsened, she began to feel embarrasse d and ashamed about her inability to control it despite insight into its consequence s. Her husband supported her in seeking treatment, but after years of arguments over financia l issues and broken promises regarding jointly negotiated budgets, her marriage was at risk of joining the long list of things she had sacrifice d for shopping. She had sought help with money management through Debtors Anonymous, who were helpful, but her excessive buying behavior continued, creating cycles of debt, bankruptcy and repayment. Her purchases focused on expensive jewelry and clothing, and she often became preoccupied with items seen in store windows or advertisemen ts until she could buy them. To avoid arguments , she kept new items in the trunk of her car or other temporary locations out of her husband’s sight. Her clothing and jewelry `collection’ far surpasse d what she could store in her home, requiring her to rent storage space for racks and crates of unused clothing, much of it with the store tags still attached. Returning or giving
away any of it was unthinkable. She described feeling that she deserved each of these purchases, and could not part with them. Even when she tried indexing her possession s in an attempt to remind herself of what she had and help curb her need to buy, she felt that new purchase s were a necessity, and that each was distinct and valuable in its own way, even if it was her fourteenth white T-shirt.
CASE STUDY 2 Mr B, a single 40-year-old lawyer, reported that his compulsive buying, although not resulting in bankruptcy, was extremely disruptive of his familial , romantic and professiona l relationships . His ``financia l irresponsibi lity’’ was earning him an embarrassin g reputation at work, despite his discipline and accomplishments in other areas. Occasionall y the feedback from colleague s and the humiliation became so intolerable that he had difficult y interacting with coworkers and clients, and sometimes did not come to the office at all. Relationship s with siblings and parents were strained after years of borrowing money he couldn’t repay. At family holiday gatherings he often felt compelled to take the special opportunity to visit nearby book or electronics stores, missing time with his family and further entangling himself in debt, social isolation and the criticism he wished to avoid. The most heart-breaki ng consequence , by his report, was the toll his buying behavior took on romantic relationships . He described being unable to save money for a house, a larger apartment or a vacation despite his high salary. Many of his relationship s ended prematurely due to difficult y in managing joint finances, and conflict over misinterpret ation of his buying behavior as rebellious , defiant or controlling . He described it instead as distressin g and out of his control, ``a weakness’’ . He purchased computer equipment, classical literature, and expensive pens. He identified his purchases as clearly excessive, describing an apartment lined with shelves of unread books, and a garage and storage unit with boxed electronics and more books. Although he described many of his purchases as ``mindless , compulsive acts’’, he did not return the items. He felt he could not part with items that seemed to characterize aspects of himself: intellectual, hard-worki ng, efficient , a knowledgeab le and gifted writer.
DISCUSSION Two case vignettes cannot capture all of the individual variations in compulsive shopping behavior. However, these cases illustrate some common features1 ± 10 which are useful for identifying and treating compulsive shoppers. A sense of behavioral lack of control is frequently reported, despite the subject being discipline d and accomplishe d in other areas, having money management skills and insight into the consequence s of excessive buying. Feelings of shame and embarrassme nt often occur after uncontrolled
Int J Psych Clin Pract Downloaded from informahealthcare.com by University of California Irvine on 11/07/14 For personal use only.
Two illustrative cases of compulsive shopping
buying and may result in social avoidance, low self-esteem and disrupted relationships . Although descriptive studies report a high rate of comorbidity with other impulse control and axis I disorders,2,9,12 many of the individual s we worked with reported compulsive shopping behavior as a long-standin g, primary clinical issue. Preoccupation with, and purchase of, items beyond one’s means, clearly in excess of what is needed, is qualitatively differen t than shopping as a social outlet or a recreational pastime. It is also distinct from the hoarding often seen in obsessive ± compulsive disorder (OCD). Hoarded items are more often everyday, inexpensiv e things that have been gathered over time, such as receipts, mail, newspapers , magazines, old clothes, packaging materials or toothbrushes; hoarding is motivated by obsessiona l fears that the items or information in them may be needed some day, and that the loss of items may result in horrible consequence s for the individua l or a loved one; hoarding is rarely associated with debt or excessive spending; and the isolation experienced by hoarders is more often due to living situations crowded with disorganize d (to the onlooker) piles and boxes of saved items. In contrast, chronic over-buying behavior and its resultant financial consequence s appear to be the characterizing features in compulsive shopping, although reluctance to return items is also a factor. The act of buying is described as having `addictive’ properties, and the debt, `financial irresponsibi lity’ and behavioral lack of control are the main sources of distress. Many compulsive shoppers prefer to ultimately give items away, rather than return them to the store to make room for new purchases. In the spectrum of compulsive (anxiety-driv en, fear-avoidin g) versus impulsive (reflexive , `automatic’) behavior described by Hollander et al, 13 compulsive shopping appears more consistent with impulsive behavior, while OCD hoarding has a clear affinity with the compulsive end of the spectrum. Compulsive buying is also distinct from the excessive buying seen in manic episodes. Unlike the episodic spending in bipolar disorder, compulsive shopping behavior is reported by patients to be a continuous, long-standin g problem, and is not accompanied by flight of ideas, decreased sleep, increased energy or other symptoms of mania.
PSYCHOTHERAPY AND MEDICATION TREATMENTS A few research groups are investigating medication treatments for compulsive shopping.6,8,14,15 Clinical case studies and research trials report the use of SSRIs such as citalopram and fluvoxamine . These treatment trials grew out of success in the use of SSRIs for treatment of other impulse control and OC spectrum disorders.16 Resonse to treatment by compulsive shoppers has been reported good in many case studies;6,8,15 however, in the only published double-blin d study to date, active medication was no more effective than placebo.14 Therapeutic spending diaries kept by the placebo group were thought to be a potential
67
confoundin g factor in identifying the effectivenes s of the SSRI; however, this would suggest that behavioral therapy may be another effective treatment approach. Our group has begun a 10-week double-blind study to help clarify the effectivenes s of SSRIs for this disorder. There have been no published reports describing psychotherapy-focused treatment trials for compulsive shopping. However, a group psychotherapy study is under way in our research clinic, examining the effectivene ss of cognitive behavioral (CBT), dialectical behavioral (DBT) and other techniques. The cognitive behavioral group data have been collected and results are promising. Some of the key technique s used in the 10-week cognitive behavioral group included in-group sharing of monitoring forms (a daily record sheet of impulsive purchases and urges to shop). Cognitive restructuri ng worksheet s, completed as homework and discussed with the group, helped identify distortions in thinking and emotional reasoning about feeling the `need’ to buy certain objects. During group discussion s, patients were encouraged to help each other identify distortions in thinking, recognize the importance of incorporat ing pleasant activities into their schedule and plan alternate activities for their high-ris k shopping times. Data describing the effectiveness of dialectical behavioral and other therapy techniques will be collected as the study progresses . These and other additional studies are needed to improve public awareness of compulsive shopping behavior and to make it known that help is available for people who struggle with this problem. Review of clinical cases and treatments, as offered in this paper, increases our understanding of the phenomenolog y, differentia l diagnosis, etiology and treatment of this disorder.
ACKNOWLEDGEMENTS We gratefully acknowledge the assistance of Michael Elliott MA, Kim Bullock MD, Helen Chuong MA, Rosell Jefferies and Patricia Moran for their help with screening and interviewin g subjects.
KEY POINTS . Compulsive shopping is a valid form of DSM-IV Impulse Control Disorders Not Otherwise Specified . Diagnostic criteria have been established to identify the disorder . Compulsive shopping is clearly distinguisha ble from OCD hoarding and the excessive buying associated with mania . Compulsive shopping behavior can cause serious disruptions in work, social and family functioning . Treatment outcome studies using SSRIs or psychotherap y are under way
68
HJ Hartston and LM Koran
Int J Psych Clin Pract Downloaded from informahealthcare.com by University of California Irvine on 11/07/14 For personal use only.
REFERENCES 1. Lawrence L (1990) The psychodynamics of the compulsive female shopper. Am J Psychoanalysis 50: 67 ± 70. 2. Christenson GA, Faber RJ, de Zwaan M et al (1994) Compulsive buying: Descriptive characteristics and psychiatric comorbidity. J Clin Psychiatry 55: 5 ± 11. 3. McElroy SL, Keck PE, Pope HG et al (1994) Compulsive buying: A report of 20 cases. J Clin Psychiatry 55: 242 ± 8. 4. Schlosser S, Black DW, Repertinger S, Freet D (1994) Compulsive buying; demography, phenomenology, and comorbidity in 46 subjects. Gen Hosp Psychiatry 16: 205 ± 12. 5. Black DW (1996) Compulsive buying: A review. J Clin Psychiatry 57 (suppl 8): 50 ± 4. 6. Bernik MA, Akerman D, Amaral JA, Braun R (1996) Cue exposure in compulsive buying. J Clin Psychiatry 57: 90. 7. Lejoyeux M, Ades J, Tassain V, Solomon J (1996) Phenomenology and psychopathology of uncontrolled buying. Am J Psychiatry 153: 1524 ± 9. 8. Black DW, Gabel J, Schlosser S (1997) Urge to splurge. Am J Psychiatry 154: 1629 ± 30. 9. Black DW, Repertinger S, Gaffney GR, Gabel J (1998) Family history and psychiatric comorbidity in persons with compulsive buying: Preliminary findings. Am J Psychiatry 155: 960 ± 3.
10. Carmin CN (1998) Addicted women: When your patient can’t stop drinking, smoking, shopping, eating. Int J Fertil Womens Medicine 43: 179 ± 85. 11. Faber RJ, O’Guinn TC (1992) A clinical screener for compulsive buying. J Consumer Res 19: 459 ± 69. 12. Faber RJ, Christenson GA, de Zwaan M, Mitchell JE (1995) Two forms of compulsive consumption: Comorbidity of compulsive buying and binge eating. J Consumer Res 22: 296 ± 304. 13. Hollander E, Kwan J, Stein D et al (1996) Obsessive compulsive spectrum disorders: Overview and quality of life issues. J Clin Psychiatry 57: 3 ± 6. 14. Ninan PT, McElroy SL, Kane CP, et al (2000) Placebocontrolled study of fluvoxamine in the treatment of patients with compulsive buying. J Clin Psychopharmacol 20: 362 ± 66. 15. Koran LM, Bullock KD, Hartston HJ, et al (2002) Citalopram treatment of compulsive shopping: An open-label pilot study. Am J Psychiatry (In press). 16. Koran LM (1999) Obsessive-compulsive and Related Disorders in Adults: A comprehensive clinical guide. Cambridge: Cambridge University Press.
2002 Martin Dunitz Ltd
International Journal of Psychiatry in Clinical Practice 2002 Volume 6 Pages 65 ± 68
65
Impulsive behavior in a consumer culture HEIDI J HARTSTON AND LORRIN M KORAN
Int J Psych Clin Pract Downloaded from informahealthcare.com by University of California Irvine on 11/07/14 For personal use only.
Department of Psychiatry and Behavioral Sciences, Stanford University Medical Center, Stanford, CA 94305-5721, USA
Correspondence Address Heidi Hartston PhD, Obsessive Compulsive Disorder Clinic, 401 Quarry Road MC 5721, Stanford, CA 94305, USA Tel: (650) 723-8212 Fax: (650) 725-0363 E-mail: [email protected]
Received 16 May 2001; revised 2 January 2002; accepted for publication 9 January 2002
Compulsive shopping behaviour has recently received long overdue attention as a clinical issue. Curiosity about this condition has led to questions about its identification, characterization as a disorder, and treatment. INTRODUCTION:
This article presents two case vignettes illustrating diagnosti c criteria and points that distinguish this disorder from OCD hoarding or mania. These issues are discussed. METHOD:
RESULTS:
The authors present some suggested treatment approaches .
Greater awareness of the prevalence and social consequences of compulsive shopping behaviour highlights the need for treatment and for educational resources for clinicians and the general public. (Int J Psych Clin Pract 2002; 6: 65 ± 68) CONCLUSION:
Keywords compulsive shopping impulse control disorders compulsive
INTRODUCTION
R
esearchers into consumerism and researchers into mental health have become more aware of common scenarios involving `out of control’ buying behavior associated with substantial financial, marital, occupational, social and psychological consequences. In its more severe form, `compulsive shopping’, or `pathological buying’ falls within the DSM-IV category of `impulse control disorders not otherwise specified’. Whether compulsive shopping is best characterized as an obsessive ± compulsive spectrum disorder, impulse control disorder, or a behavioral reaction to major depression or another primary psychiatric disorder, remains uncertain. Descriptive papers1 ± 10 provide general descriptions and information about the demographic s and frequenc y of this behavioral problem, and case studies such as those presented in this paper can help shed more light on the underlyin g psychologica l issues and the often devastating consequence s of the behavior, and can help in guiding treatment. We also include a section on medication and psychotherapy treatments, describing empirically based approaches which are currently being explored. Compulsive shopping behavior may affect 2 ± 8% of the US population, depending on the criteria used, and appears to have a gender ratio of 9 : 1 (female to male).11 Diagnostic criteria for compulsive shopping, outlined by
pathologica l buying impulsive
McElroy et al,3 include: 1. frequent preoccupation with shopping or intrusive, irresistible , `senseless ’ buying impulses; 2. clearly buying more than is needed or can be afforded; 3. distress related to buying behavior; and 4. significan t interferenc e with work or social functioning . These criteria are consistent with those used to diagnose other impulse control disorders such as pathological gambling, kleptomania and trichotilloman ia. The phenomenology of the disorder is also similar to that of other impulse control disorders in that patients report preoccupation with buying and a preceding sense of tension, focused either on the purchase of a particular item, or on buying in general, which is relieved by the act of buying. Feelings of power, pleasure, happiness, relief or emotional numbness accompany the act of buying, and an array of consequence s follows. The frequency of problematic compulsive shopping episodes can range from once a month to once a day and the amount spent per episode varies widely, depending on availabl e funds, methods of payment (credit cards versus cash) and the type of objects typically purchased. Common items which are compulsively purchased include clothes, make-up, art, jewelry, computer equipment, books, and craft or gardening supplies. Many compulsive shoppers compare their experience to an addiction, describing time-consumi ng preoccupation, failure to fulfill major role obligations at home or work due to shopping or thinking about it, and
Int J Psych Clin Pract Downloaded from informahealthcare.com by University of California Irvine on 11/07/14 For personal use only.
66
HJ Hartston and LM Koran
recurrent problematic behavior despite legal consequence s (such as bankruptcy), social difficultie s (negative feedback from friends, family, isolation) and/or interpersona l problems (marital conflict, divorce). After a brief media announcemen t of a compulsive shopping study, our clinic received more than 200 calls from individual s reporting trouble with compulsive shopping behavior, requesting information and treatment. Publicizin g informatio n about compulsive shopping behavior may aid in the recognition of such behavior, and bring individual s out from the secrecy and shame that often accompanie s mental health issues. The following case descriptions exemplify many common features of compulsive shopping behavior. Both patients participated in a brief cognitive-be havioral group psychotherap y treatment trial for compulsive shopping (Hartston and Koran, unpublished ) and both made substantial improvement s in understandi ng and managing their shopping behavior.
CASE 1 Mrs A, a 56-year-old college professor, first sought treatment for her shopping behavior after spending years recovering from a bankruptcy and again incurring significan t debt beyond her ability to pay. She described having had difficult y with uncontrolled buying since her early twenties, when she first began to manage her own money. In her 20s and 30s, she underwent psychotherap y to address a history of child abuse, and again in her 40s to address bereavement issues after the loss of her last parent. Her spending became notably worse after receiving her inheritance, and the buying behavior continued, reportedly ``wrecking my life’’. She described her marriage as happy until financial difficultie s resulting from her shopping threatened the living situation and lifestyle of the couple and became a focus of dispute. As her shopping behavior worsened, she began to feel embarrasse d and ashamed about her inability to control it despite insight into its consequence s. Her husband supported her in seeking treatment, but after years of arguments over financia l issues and broken promises regarding jointly negotiated budgets, her marriage was at risk of joining the long list of things she had sacrifice d for shopping. She had sought help with money management through Debtors Anonymous, who were helpful, but her excessive buying behavior continued, creating cycles of debt, bankruptcy and repayment. Her purchases focused on expensive jewelry and clothing, and she often became preoccupied with items seen in store windows or advertisemen ts until she could buy them. To avoid arguments , she kept new items in the trunk of her car or other temporary locations out of her husband’s sight. Her clothing and jewelry `collection’ far surpasse d what she could store in her home, requiring her to rent storage space for racks and crates of unused clothing, much of it with the store tags still attached. Returning or giving
away any of it was unthinkable. She described feeling that she deserved each of these purchases, and could not part with them. Even when she tried indexing her possession s in an attempt to remind herself of what she had and help curb her need to buy, she felt that new purchase s were a necessity, and that each was distinct and valuable in its own way, even if it was her fourteenth white T-shirt.
CASE STUDY 2 Mr B, a single 40-year-old lawyer, reported that his compulsive buying, although not resulting in bankruptcy, was extremely disruptive of his familial , romantic and professiona l relationships . His ``financia l irresponsibi lity’’ was earning him an embarrassin g reputation at work, despite his discipline and accomplishments in other areas. Occasionall y the feedback from colleague s and the humiliation became so intolerable that he had difficult y interacting with coworkers and clients, and sometimes did not come to the office at all. Relationship s with siblings and parents were strained after years of borrowing money he couldn’t repay. At family holiday gatherings he often felt compelled to take the special opportunity to visit nearby book or electronics stores, missing time with his family and further entangling himself in debt, social isolation and the criticism he wished to avoid. The most heart-breaki ng consequence , by his report, was the toll his buying behavior took on romantic relationships . He described being unable to save money for a house, a larger apartment or a vacation despite his high salary. Many of his relationship s ended prematurely due to difficult y in managing joint finances, and conflict over misinterpret ation of his buying behavior as rebellious , defiant or controlling . He described it instead as distressin g and out of his control, ``a weakness’’ . He purchased computer equipment, classical literature, and expensive pens. He identified his purchases as clearly excessive, describing an apartment lined with shelves of unread books, and a garage and storage unit with boxed electronics and more books. Although he described many of his purchases as ``mindless , compulsive acts’’, he did not return the items. He felt he could not part with items that seemed to characterize aspects of himself: intellectual, hard-worki ng, efficient , a knowledgeab le and gifted writer.
DISCUSSION Two case vignettes cannot capture all of the individual variations in compulsive shopping behavior. However, these cases illustrate some common features1 ± 10 which are useful for identifying and treating compulsive shoppers. A sense of behavioral lack of control is frequently reported, despite the subject being discipline d and accomplishe d in other areas, having money management skills and insight into the consequence s of excessive buying. Feelings of shame and embarrassme nt often occur after uncontrolled
Int J Psych Clin Pract Downloaded from informahealthcare.com by University of California Irvine on 11/07/14 For personal use only.
Two illustrative cases of compulsive shopping
buying and may result in social avoidance, low self-esteem and disrupted relationships . Although descriptive studies report a high rate of comorbidity with other impulse control and axis I disorders,2,9,12 many of the individual s we worked with reported compulsive shopping behavior as a long-standin g, primary clinical issue. Preoccupation with, and purchase of, items beyond one’s means, clearly in excess of what is needed, is qualitatively differen t than shopping as a social outlet or a recreational pastime. It is also distinct from the hoarding often seen in obsessive ± compulsive disorder (OCD). Hoarded items are more often everyday, inexpensiv e things that have been gathered over time, such as receipts, mail, newspapers , magazines, old clothes, packaging materials or toothbrushes; hoarding is motivated by obsessiona l fears that the items or information in them may be needed some day, and that the loss of items may result in horrible consequence s for the individua l or a loved one; hoarding is rarely associated with debt or excessive spending; and the isolation experienced by hoarders is more often due to living situations crowded with disorganize d (to the onlooker) piles and boxes of saved items. In contrast, chronic over-buying behavior and its resultant financial consequence s appear to be the characterizing features in compulsive shopping, although reluctance to return items is also a factor. The act of buying is described as having `addictive’ properties, and the debt, `financial irresponsibi lity’ and behavioral lack of control are the main sources of distress. Many compulsive shoppers prefer to ultimately give items away, rather than return them to the store to make room for new purchases. In the spectrum of compulsive (anxiety-driv en, fear-avoidin g) versus impulsive (reflexive , `automatic’) behavior described by Hollander et al, 13 compulsive shopping appears more consistent with impulsive behavior, while OCD hoarding has a clear affinity with the compulsive end of the spectrum. Compulsive buying is also distinct from the excessive buying seen in manic episodes. Unlike the episodic spending in bipolar disorder, compulsive shopping behavior is reported by patients to be a continuous, long-standin g problem, and is not accompanied by flight of ideas, decreased sleep, increased energy or other symptoms of mania.
PSYCHOTHERAPY AND MEDICATION TREATMENTS A few research groups are investigating medication treatments for compulsive shopping.6,8,14,15 Clinical case studies and research trials report the use of SSRIs such as citalopram and fluvoxamine . These treatment trials grew out of success in the use of SSRIs for treatment of other impulse control and OC spectrum disorders.16 Resonse to treatment by compulsive shoppers has been reported good in many case studies;6,8,15 however, in the only published double-blin d study to date, active medication was no more effective than placebo.14 Therapeutic spending diaries kept by the placebo group were thought to be a potential
67
confoundin g factor in identifying the effectivenes s of the SSRI; however, this would suggest that behavioral therapy may be another effective treatment approach. Our group has begun a 10-week double-blind study to help clarify the effectivenes s of SSRIs for this disorder. There have been no published reports describing psychotherapy-focused treatment trials for compulsive shopping. However, a group psychotherapy study is under way in our research clinic, examining the effectivene ss of cognitive behavioral (CBT), dialectical behavioral (DBT) and other techniques. The cognitive behavioral group data have been collected and results are promising. Some of the key technique s used in the 10-week cognitive behavioral group included in-group sharing of monitoring forms (a daily record sheet of impulsive purchases and urges to shop). Cognitive restructuri ng worksheet s, completed as homework and discussed with the group, helped identify distortions in thinking and emotional reasoning about feeling the `need’ to buy certain objects. During group discussion s, patients were encouraged to help each other identify distortions in thinking, recognize the importance of incorporat ing pleasant activities into their schedule and plan alternate activities for their high-ris k shopping times. Data describing the effectiveness of dialectical behavioral and other therapy techniques will be collected as the study progresses . These and other additional studies are needed to improve public awareness of compulsive shopping behavior and to make it known that help is available for people who struggle with this problem. Review of clinical cases and treatments, as offered in this paper, increases our understanding of the phenomenolog y, differentia l diagnosis, etiology and treatment of this disorder.
ACKNOWLEDGEMENTS We gratefully acknowledge the assistance of Michael Elliott MA, Kim Bullock MD, Helen Chuong MA, Rosell Jefferies and Patricia Moran for their help with screening and interviewin g subjects.
KEY POINTS . Compulsive shopping is a valid form of DSM-IV Impulse Control Disorders Not Otherwise Specified . Diagnostic criteria have been established to identify the disorder . Compulsive shopping is clearly distinguisha ble from OCD hoarding and the excessive buying associated with mania . Compulsive shopping behavior can cause serious disruptions in work, social and family functioning . Treatment outcome studies using SSRIs or psychotherap y are under way
68
HJ Hartston and LM Koran
Int J Psych Clin Pract Downloaded from informahealthcare.com by University of California Irvine on 11/07/14 For personal use only.
REFERENCES 1. Lawrence L (1990) The psychodynamics of the compulsive female shopper. Am J Psychoanalysis 50: 67 ± 70. 2. Christenson GA, Faber RJ, de Zwaan M et al (1994) Compulsive buying: Descriptive characteristics and psychiatric comorbidity. J Clin Psychiatry 55: 5 ± 11. 3. McElroy SL, Keck PE, Pope HG et al (1994) Compulsive buying: A report of 20 cases. J Clin Psychiatry 55: 242 ± 8. 4. Schlosser S, Black DW, Repertinger S, Freet D (1994) Compulsive buying; demography, phenomenology, and comorbidity in 46 subjects. Gen Hosp Psychiatry 16: 205 ± 12. 5. Black DW (1996) Compulsive buying: A review. J Clin Psychiatry 57 (suppl 8): 50 ± 4. 6. Bernik MA, Akerman D, Amaral JA, Braun R (1996) Cue exposure in compulsive buying. J Clin Psychiatry 57: 90. 7. Lejoyeux M, Ades J, Tassain V, Solomon J (1996) Phenomenology and psychopathology of uncontrolled buying. Am J Psychiatry 153: 1524 ± 9. 8. Black DW, Gabel J, Schlosser S (1997) Urge to splurge. Am J Psychiatry 154: 1629 ± 30. 9. Black DW, Repertinger S, Gaffney GR, Gabel J (1998) Family history and psychiatric comorbidity in persons with compulsive buying: Preliminary findings. Am J Psychiatry 155: 960 ± 3.
10. Carmin CN (1998) Addicted women: When your patient can’t stop drinking, smoking, shopping, eating. Int J Fertil Womens Medicine 43: 179 ± 85. 11. Faber RJ, O’Guinn TC (1992) A clinical screener for compulsive buying. J Consumer Res 19: 459 ± 69. 12. Faber RJ, Christenson GA, de Zwaan M, Mitchell JE (1995) Two forms of compulsive consumption: Comorbidity of compulsive buying and binge eating. J Consumer Res 22: 296 ± 304. 13. Hollander E, Kwan J, Stein D et al (1996) Obsessive compulsive spectrum disorders: Overview and quality of life issues. J Clin Psychiatry 57: 3 ± 6. 14. Ninan PT, McElroy SL, Kane CP, et al (2000) Placebocontrolled study of fluvoxamine in the treatment of patients with compulsive buying. J Clin Psychopharmacol 20: 362 ± 66. 15. Koran LM, Bullock KD, Hartston HJ, et al (2002) Citalopram treatment of compulsive shopping: An open-label pilot study. Am J Psychiatry (In press). 16. Koran LM (1999) Obsessive-compulsive and Related Disorders in Adults: A comprehensive clinical guide. Cambridge: Cambridge University Press.
