Letters to the Editors
11. Walinder J, Wallin L, Carlsson A. Effect of baclofen on cerebrospinal-fluid levels of 5-hydroxyindoleacetic acid and homovanillic acid. N Engl J Med. 1977; 296(8):452Y453. 12. Knutsson E, Lindblom U, Martensson A. Plasma and cerebrospinal fluid levels of baclofen (Lioresal) at optimal therapeutic responses in spastic paresis. J Neurol Sci. 1974;23(3):473Y484. 13. Albright AL, Thompson K, Carlos S, et al. Cerebrospinal fluid baclofen concentrations in patients undergoing continuous intrathecal baclofen therapy. Dev Med Child Neurol. 2007;49(6):423Y425. 14. Abellan MT, Jolas T, Aghajanian GK, et al. Dual control of dorsal raphe serotonergic neurons by GABA(B) receptors. Electrophysiological and microdialysis studies. Synapse. 2000;36(1):21Y34. 15. Meythaler JM, Roper JF, Brunner RC. Cyproheptadine for intrathecal baclofen withdrawal. Arch Phys Med Rehabil. 2003;84(5):638Y642. 16. Barbeau H, Bedard P. Denervation supersensitivity to 5-hydroxytryptophan in rats following spinal transection and 5,7-dihydroxytryptamine injection. Neuropharmacology. 1981;20(6):611Y616. 17. Murray KC, Stephens MJ, Ballou EW, et al. Motoneuron excitability and muscle spasms are regulated by 5-HT2B and 5-HT2C receptor activity. J Neurophysiol 2011;105(2): 731Y748. 18. Tyacke RJ, Lingford-Hughes A, Reed LJ, et al. GABAB receptors in addiction and its treatment. Adv Pharmacol. 2010;58: 373Y396. 19. Shin R, Ikemoto S. The GABAB receptor agonist baclofen administered into the median and dorsal raphe nuclei is rewarding as shown by intracranial self-administration and conditioned place preference in rats. Psychopharmacology (Berl). 2010;208(4): 545Y554. 20. Volkow ND, Wang GJ, Telang F, et al. Cocaine cues and dopamine in dorsal striatum: mechanism of craving in cocaine addiction. J Neurosci. 2006;26(24): 6583Y6588.
Topiramate and Compulsive Buying Disorder To the Editors: ompulsive buying disorder is characterized by long-term, repetitive purchasing having adverse consequences. Point prevalence is estimated at 5.8% among respondents in the United States.1 Comorbidities include depression, anxiety, and substance abuse. Documented response to prescribed antidepressant drugs remains unclear.2Y4
C
174
www.psychopharmacology.com
Journal of Clinical Psychopharmacology
Topiramate is a medication used in treating seizures, bipolar disorder, binge eating, and substance abuse. A patient prescribed topiramate for a compulsive buying disorder is presented.
CASE A 42-year-old woman with obesity was being treated for depression and anxiety. Diagnoses included type II bipolar disorder, generalized anxiety, and obsessive compulsive disorder. She exhibited chronic trichotillomania, which resulted in alopecia. Compulsive shopping began at age 20, a worse problem when coexistent with depression and less overt during hypomania. She smoked cannabis 20 years ago and currently drinks alcohol a few times per year, periodically becoming intoxicated. Shopping was a 3-hour-per-day activity, usually for clothing, and spending in excess of her budget. After purchasing, she experienced guilt and remorse, hiding the obtained items from her husband or alternatively giving him gifts. She felt too embarrassed to return items. This behavior was uncontrolled and disturbing to her. It resulted in dysfunction and financial debt. Prescribed medications were ineffective over the years and had included several antidepressant drugs, antipsychotic medicines, mood stabilizers, benzodiazepines, and buspirone. Cognitive-behavioral therapy and dialectical behavior therapy were also not effective, leaving her depressed and anxious. In recent months, aripiprazole was prescribed 15 mg daily, and 50 mg of lamotrigine was started for the past week. Topiramate was initiated and titrated to 100 mg/d in an attempt to augment mood stabilizer effects. Her compulsive buying behavior significantly improved on treatment day 4. She was able to control her buying behavior, but depression and anxiety did not improve. Lamotrigine and aripiprazole dosages were unchanged. After 6 weeks of topiramate therapy, the Yale-Brown Obsessive Compulsive ScaleShopping Version score dropped to 5, down from 31. The patient reported weight loss. Hair pulling behavior also decreased in frequency. Dosage adjustment in the medications resulted in reduced depression and anxiety at 300 mg of topiramate and 150 mg of lamotrigine daily. Then, the dosage of topiramate was increased to 350 mg/d and yielded continued progress for more than 6 months. Aripiprazole was discontinued because of ineffectiveness on that and previous trials. Her weight stabilized. She was able to control her compulsive buying behavior throughout the Christmas shopping season that previously had troubled her for
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Volume 34, Number 1, February 2014
years. Her social, occupational, and family functions improved.
DISCUSSION A variety of psychotropic medicines are inconsistently effective for compulsive disorders.2Y4 Topiramate quickly induced and maintained progress in this patient for more than half a year. It may be a useful adjunct for people with compulsive buying disorder that is comorbid with other psychiatric disorders; use as a primary agent could be considered. Rapid dosage titration can result in a faster response, and this doseescalation regimen may have been instrumental in her progress. The improvement in compulsive buying behavior occurred early and was not paralleled to the slower response of depressive and anxiety symptoms. This suggests that the primary effects of topiramate are on compulsive behaviors rather than secondary to an influence on comorbid conditions. Compulsive buying disorder has varying ideologies. Many pharmaceuticals target serotonin, glutamate, and opioid systems.5 Topiramate, a F-aminobutyric acidYenhancing agent, may offer an alternative strategy for patients with such conditions. The observed effects on impulse control are consistent with earlier reports documenting that topiramate is useful in diminishing aggression,6 binge eating disorders, and alcohol dependence7; however, the fact that topiramate fails to mitigate pathological gambling might challenge this contention.8 The differing ideologies contribute to mixed results. Lamotrigine can cause erythema multiforme, even Stevens-Johnson syndrome, if it is given in large starting dosages or exceeding recommended titrations. The need for gradual dose titration has limited its short-term illness use. Topiramate offers the advantage of being able to be quickly titrated for rapid stabilization. Topiramate appeared to be effective at reducing compulsive buying disorder and diminishing trichotillomania, while also improving mood. Weight loss was noted as well. Topiramate may be an option in treating other compulsivity concerns or related disorders. AUTHOR DISCLOSURE INFORMATION The authors declare no conflicts of interest. Written informed consent was obtained from the patient about publication of this report. A copy is available on request. The authors were the only persons preparing this manuscript. * 2014 Lippincott Williams & Wilkins
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Journal of Clinical Psychopharmacology
&
Volume 34, Number 1, February 2014
Lu Ye, MD Department of Psychiatry Methodist Medical Center of Illinois Peoria, IL [email protected]
Snehal Kadia, MD Steven Lippmann, MD Department of Psychiatry University of Louisville School of Medicine Louisville, KY
REFERENCES 1. Koran LM, Faber RJ, Aboujaoude E, et al. Estimated prevalence of compulsive buying behavior in the United States. Am J Psychiatry. 2006;163(10): 1806Y1812.
* 2014 Lippincott Williams & Wilkins
2. Koran LM, Aboujaoude EN, Solvason B, et al. Escitalopram for compulsive buying disorder: a double-blind discontinuation study. J Clin Psychopharmacol. 2007; 27(2):225Y227. 3. Black DW, Gabel J, Hansen J, et al. A double-blind comparison of fluvoxamine versus placebo in the treatment of compulsive buying disorder. Ann Clin Psychiatry. 2000;12(4):205Y211. 4. Koran LM, Chuong HW, Bullock KD, et al. Citalopram for compulsive shopping disorder: an open-label study followed by double-blind discontinuation. J Clin Psychiatry. 2003;64(7):793Y798. 5. Grant JE. Three cases of compulsive buying treated with naltrexone.
Letters to the Editors
Int J Psychiatry Clin Pract. 2003;7: 223Y225. 6. Lane SD, Gowin JL, Green CE, et al. Acute topiramate differentially affects human aggressive responding at low vs. moderate doses in subjects with histories of substance abuse and antisocial behavior. Pharmacol Biochem Behav. 2009;92(2):357Y362. 7. Johnson BA, Ait-Daoud N, Bowden CL, et al. Oral topiramate for treatment of alcohol dependence: a randomised controlled trial. Lancet. 2003;361(9370):1677Y1685. 8. Berlin HA, Braun A, Simeon D, et al. A double-blind, placebo-controlled trial of topiramate for pathological gambling. World J Biol Psychiatry. 2013. 14(2):121Y128.
www.psychopharmacology.com
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
175
11. Walinder J, Wallin L, Carlsson A. Effect of baclofen on cerebrospinal-fluid levels of 5-hydroxyindoleacetic acid and homovanillic acid. N Engl J Med. 1977; 296(8):452Y453. 12. Knutsson E, Lindblom U, Martensson A. Plasma and cerebrospinal fluid levels of baclofen (Lioresal) at optimal therapeutic responses in spastic paresis. J Neurol Sci. 1974;23(3):473Y484. 13. Albright AL, Thompson K, Carlos S, et al. Cerebrospinal fluid baclofen concentrations in patients undergoing continuous intrathecal baclofen therapy. Dev Med Child Neurol. 2007;49(6):423Y425. 14. Abellan MT, Jolas T, Aghajanian GK, et al. Dual control of dorsal raphe serotonergic neurons by GABA(B) receptors. Electrophysiological and microdialysis studies. Synapse. 2000;36(1):21Y34. 15. Meythaler JM, Roper JF, Brunner RC. Cyproheptadine for intrathecal baclofen withdrawal. Arch Phys Med Rehabil. 2003;84(5):638Y642. 16. Barbeau H, Bedard P. Denervation supersensitivity to 5-hydroxytryptophan in rats following spinal transection and 5,7-dihydroxytryptamine injection. Neuropharmacology. 1981;20(6):611Y616. 17. Murray KC, Stephens MJ, Ballou EW, et al. Motoneuron excitability and muscle spasms are regulated by 5-HT2B and 5-HT2C receptor activity. J Neurophysiol 2011;105(2): 731Y748. 18. Tyacke RJ, Lingford-Hughes A, Reed LJ, et al. GABAB receptors in addiction and its treatment. Adv Pharmacol. 2010;58: 373Y396. 19. Shin R, Ikemoto S. The GABAB receptor agonist baclofen administered into the median and dorsal raphe nuclei is rewarding as shown by intracranial self-administration and conditioned place preference in rats. Psychopharmacology (Berl). 2010;208(4): 545Y554. 20. Volkow ND, Wang GJ, Telang F, et al. Cocaine cues and dopamine in dorsal striatum: mechanism of craving in cocaine addiction. J Neurosci. 2006;26(24): 6583Y6588.
Topiramate and Compulsive Buying Disorder To the Editors: ompulsive buying disorder is characterized by long-term, repetitive purchasing having adverse consequences. Point prevalence is estimated at 5.8% among respondents in the United States.1 Comorbidities include depression, anxiety, and substance abuse. Documented response to prescribed antidepressant drugs remains unclear.2Y4
C
174
www.psychopharmacology.com
Journal of Clinical Psychopharmacology
Topiramate is a medication used in treating seizures, bipolar disorder, binge eating, and substance abuse. A patient prescribed topiramate for a compulsive buying disorder is presented.
CASE A 42-year-old woman with obesity was being treated for depression and anxiety. Diagnoses included type II bipolar disorder, generalized anxiety, and obsessive compulsive disorder. She exhibited chronic trichotillomania, which resulted in alopecia. Compulsive shopping began at age 20, a worse problem when coexistent with depression and less overt during hypomania. She smoked cannabis 20 years ago and currently drinks alcohol a few times per year, periodically becoming intoxicated. Shopping was a 3-hour-per-day activity, usually for clothing, and spending in excess of her budget. After purchasing, she experienced guilt and remorse, hiding the obtained items from her husband or alternatively giving him gifts. She felt too embarrassed to return items. This behavior was uncontrolled and disturbing to her. It resulted in dysfunction and financial debt. Prescribed medications were ineffective over the years and had included several antidepressant drugs, antipsychotic medicines, mood stabilizers, benzodiazepines, and buspirone. Cognitive-behavioral therapy and dialectical behavior therapy were also not effective, leaving her depressed and anxious. In recent months, aripiprazole was prescribed 15 mg daily, and 50 mg of lamotrigine was started for the past week. Topiramate was initiated and titrated to 100 mg/d in an attempt to augment mood stabilizer effects. Her compulsive buying behavior significantly improved on treatment day 4. She was able to control her buying behavior, but depression and anxiety did not improve. Lamotrigine and aripiprazole dosages were unchanged. After 6 weeks of topiramate therapy, the Yale-Brown Obsessive Compulsive ScaleShopping Version score dropped to 5, down from 31. The patient reported weight loss. Hair pulling behavior also decreased in frequency. Dosage adjustment in the medications resulted in reduced depression and anxiety at 300 mg of topiramate and 150 mg of lamotrigine daily. Then, the dosage of topiramate was increased to 350 mg/d and yielded continued progress for more than 6 months. Aripiprazole was discontinued because of ineffectiveness on that and previous trials. Her weight stabilized. She was able to control her compulsive buying behavior throughout the Christmas shopping season that previously had troubled her for
&
Volume 34, Number 1, February 2014
years. Her social, occupational, and family functions improved.
DISCUSSION A variety of psychotropic medicines are inconsistently effective for compulsive disorders.2Y4 Topiramate quickly induced and maintained progress in this patient for more than half a year. It may be a useful adjunct for people with compulsive buying disorder that is comorbid with other psychiatric disorders; use as a primary agent could be considered. Rapid dosage titration can result in a faster response, and this doseescalation regimen may have been instrumental in her progress. The improvement in compulsive buying behavior occurred early and was not paralleled to the slower response of depressive and anxiety symptoms. This suggests that the primary effects of topiramate are on compulsive behaviors rather than secondary to an influence on comorbid conditions. Compulsive buying disorder has varying ideologies. Many pharmaceuticals target serotonin, glutamate, and opioid systems.5 Topiramate, a F-aminobutyric acidYenhancing agent, may offer an alternative strategy for patients with such conditions. The observed effects on impulse control are consistent with earlier reports documenting that topiramate is useful in diminishing aggression,6 binge eating disorders, and alcohol dependence7; however, the fact that topiramate fails to mitigate pathological gambling might challenge this contention.8 The differing ideologies contribute to mixed results. Lamotrigine can cause erythema multiforme, even Stevens-Johnson syndrome, if it is given in large starting dosages or exceeding recommended titrations. The need for gradual dose titration has limited its short-term illness use. Topiramate offers the advantage of being able to be quickly titrated for rapid stabilization. Topiramate appeared to be effective at reducing compulsive buying disorder and diminishing trichotillomania, while also improving mood. Weight loss was noted as well. Topiramate may be an option in treating other compulsivity concerns or related disorders. AUTHOR DISCLOSURE INFORMATION The authors declare no conflicts of interest. Written informed consent was obtained from the patient about publication of this report. A copy is available on request. The authors were the only persons preparing this manuscript. * 2014 Lippincott Williams & Wilkins
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Journal of Clinical Psychopharmacology
&
Volume 34, Number 1, February 2014
Lu Ye, MD Department of Psychiatry Methodist Medical Center of Illinois Peoria, IL [email protected]
Snehal Kadia, MD Steven Lippmann, MD Department of Psychiatry University of Louisville School of Medicine Louisville, KY
REFERENCES 1. Koran LM, Faber RJ, Aboujaoude E, et al. Estimated prevalence of compulsive buying behavior in the United States. Am J Psychiatry. 2006;163(10): 1806Y1812.
* 2014 Lippincott Williams & Wilkins
2. Koran LM, Aboujaoude EN, Solvason B, et al. Escitalopram for compulsive buying disorder: a double-blind discontinuation study. J Clin Psychopharmacol. 2007; 27(2):225Y227. 3. Black DW, Gabel J, Hansen J, et al. A double-blind comparison of fluvoxamine versus placebo in the treatment of compulsive buying disorder. Ann Clin Psychiatry. 2000;12(4):205Y211. 4. Koran LM, Chuong HW, Bullock KD, et al. Citalopram for compulsive shopping disorder: an open-label study followed by double-blind discontinuation. J Clin Psychiatry. 2003;64(7):793Y798. 5. Grant JE. Three cases of compulsive buying treated with naltrexone.
Letters to the Editors
Int J Psychiatry Clin Pract. 2003;7: 223Y225. 6. Lane SD, Gowin JL, Green CE, et al. Acute topiramate differentially affects human aggressive responding at low vs. moderate doses in subjects with histories of substance abuse and antisocial behavior. Pharmacol Biochem Behav. 2009;92(2):357Y362. 7. Johnson BA, Ait-Daoud N, Bowden CL, et al. Oral topiramate for treatment of alcohol dependence: a randomised controlled trial. Lancet. 2003;361(9370):1677Y1685. 8. Berlin HA, Braun A, Simeon D, et al. A double-blind, placebo-controlled trial of topiramate for pathological gambling. World J Biol Psychiatry. 2013. 14(2):121Y128.
www.psychopharmacology.com
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
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