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Abstract

Impulsive–compulsive buying disorder (ICBD) is an impulse control disorder not otherwise specified (ICD-NOS) characterized by impulsive drives and compulsive behaviours (buying unneeded things), personal distress, impaired social and vocational functioning and financial problems. Despite being described in the 19th century, serious attention to ICBD began only in the last decade with the first epidemiological and pharmacological investigation. Biological, social and psychological factors contribute to the aetiology of ICBD. Cognitive–behavioural therapy and selective serotonin re-uptake inhibitors are currently considered the more effective interventions in the treatment of ICBD. The present review aims to provide a broad overview of the epidemiology, aetiology, phenomenology and treatment options of ICBD.

Keywords

impulse control disorder not otherwise specified (ICD-NOS)impulsive–compulsive buying disorder (ICBD)

Impulsive–compulsive buying disorder (ICBD) was first described in 1915 by the German psychiatrist Emil Kraepelin who called the disorder ‘oniomania’ and the affected patients ‘buying maniacs’ [1]. Over the years, buying or shopping that is out of control and creating problems has been referred to as compulsive shopping [2], [3], compulsive consumption [4], compulsive buying [5], [6], addictive buying [7], uncontrolled buying [8], excessive buying [9] and ‘spendaholism’ [10]. In his Textbook of psychiatry, Bleuler considered ICBD as an impulsive reactive disorder, aligning his description with Esquirol's previous concept (1838) of ‘instinctive impulse’ or monomania, defined as an excessive focusing of attention on one object or issue [11]. In the 1990s there was a renewed interest in disorders characterized by behavioural excess, such as ICBD, and to the first epidemiological studies assessing the prevalence of the disorder, in part due to the potential effectiveness of pharmacological interventions such as the serotonin re-uptake inhibitors (SRIs) in relieving symptoms of mental disorders with characteristics that overlap with obsessive–compulsive disorder (OCD) [3], [12]. Nonetheless, some authors still question the attempt to categorize ICBD as a mental condition, criticizing the ongoing trend to medicalize behavioural problems that can be viewed from other perspectives, such as moral or legal [13]. In particular ICBD can be viewed within the context of the consumption-driven economy of North America and Europe [14].

Aside from its utilitarian function, shopping can be viewed as a leisure activity [15], as a way to manage emotions [16] or to establish and express self-identity [9]. Although some cases of uncontrolled buying can be interpreted as deviant, impulsive buying is widespread and cannot in itself be considered pathological given the modern marketplace and the power of the mass media in influencing people's behaviour and lifestyle [17].

Faber and O'Guinn defined compulsive buying as a chronic, repetitive purchasing that represents a primary response to stress and negative events [18]. McElroy et al. proposed an operational definition for clinical and research use, pointing out that ICBD has both cognitive and behavioural components [8]. From this point of view diagnostic criteria include (i) maladaptive preoccupation with buying or shopping, or maladaptive buying or shopping impulses; (ii) generation of marked distress by the buying preoccupations, impulses or behaviours, which are time consuming, significantly interfere with social or occupational functioning or result in financial problems; (iii) lack of restriction of the excessive buying or shopping behaviour to periods of hypomania or mania.

Neither the DSM IV-TR nor the ICD-10 include ICBD as an autonomous disorder [19], [20], but patients with this condition may be classified in the DSM system as suffering from an impulse control disorder not otherwise specified (ICD-NOS).

As for other ICDs, important defining criteria for ICBD would include the failure to resist an impulse to perform some act that is harmful to the individual or others; an increasing sense of arousal or tension prior to committing or engaging in the act; and an experience of either pleasure, gratification or release of tension while committing the act. A decrease in arousal and feelings of guilt and remorse may occur afterwards [21].

In terms of clinical presentation and pharmacological treatment, some researchers have noted overlapping features between ICDs such as ICBD and OCD [3], [8], [12], and research in this field has led a DSM-V task force to consider including some new disorders, such as ICBD, within the category of ICDs and to incorporate many of these disorders in a new autonomous subgroup of disorders (i.e. the obsessive–compulsive spectrum disorders) [22], [23]. In contrast, other investigators have noted that ICBD may belong to the spectrum of behavioural and substance addictions characterized by impulsive choice, reward sensitivity and frontostriatal circuit impairment [24], [25].

Epidemiology

The first epidemiological studies on ICBD date from the last decade. Faber and O'Guinn used the Compulsive Buying Scale (CBS) [26], a clinically validated screening instrument, to investigate the prevalence of compulsive buying in the USA, reporting estimates between 1.8% and 8.1% [18]. The two figures correspond to different thresholds set for the definition of the disorder based on the CBS score. A recent extensive investigation, performed on a general US population sample by means of national household telephone survey and through CBS, reported a point prevalence of 5.8% for ICBD [27]. Compared with healthy controls, compulsive buyers were more frequently younger and a greater proportion reported incomes under US$50 000. Moreover, they exhibited more maladaptive responses on most consumer behaviour measures and were less likely to pay off credit card balances in full. In most clinical studies, ICBD has a female preponderance ranging from 80% to 95% [8], [28–30], but the general population survey found no significant differences between genders [27]. The differing results between clinical studies and the survey might be due to a greater willingness of women to seek treatment, as has been found for depressive and anxiety disorders [31].

A recent survey investigated the prevalence of ICBD by interviewing female customers of a famous Parisian department store and reported a percentage of 32.5% of potentially affected subjects in this specific setting [32].

Aetiology

With regard to aetiologic factors that contribute to the development of ICBD, the majority of investigation in the field focused on the role of psychological and social factors with few genetics studies. Among these, a study comparing 21 patients with ICBD and 38 healthy controls failed to find an association between two serotonin transporter gene polymorphisms and ICBD [33], whereas a previous study had reported an association of ICBD with the gene of the dopamine receptor D1 (DRD1) [34].

Several authors have argued that social, economic and family factors play an important role in the aetiology of ICBD. The easy availability of credit cards, increased and more effective advertising, the possibility of buying through home shopping TV shows and the Internet, as well as the destruction of family structure and a breakdown in the sense of community have been indicated as factors contributing to the onset of ICBD [35–38]. In line with this hypothesis, a French interview survey conducted among female customers of a department store reported that, compared to controls, compulsive buyers were less likely to be married, to spend more time speaking on their mobile phones and to be connected to online shopping sites [32]. A recent study indicated that the endorsement of materialistic values is one of the strongest predictors of compulsive buying [39]. ICBD is so strongly linked to social context that some authors posed the question of whether uncontrolled buying is part of a continuum, as an extreme case of a generalized urge to buy [7]. The severe form of the disorder seems to be associated with lower income; in addition, compared to normal shoppers, compulsive buyers spend a greater proportion of their income on shopping, but spending a smaller proportion on sale items [40].

Compulsive buying may be motivated by negative feelings, commonly sadness, and maintained by reinforcement as the negative emotions are dissipated or supplanted by euphoria or other positive experiences while buying [41]. From this point of view, uncontrolled buying can be understood as a compensatory behaviour that temporarily alleviates depressive symptoms [42].

Comorbidity

People with ICBD often meet criteria for other Axis I and/or Axis II disorders [29]. A study comparing individuals who exhibited compulsive and non-compulsive buying reported that anxiety disorders, eating disorders, substance use disorders and impulse control disorders were significantly more frequent among those who buy compulsively [29].

A study comparing German compulsive buyers to US ones found significantly higher comorbid rates of any affective disorder, any anxiety disorder and somatoform disorder in the German buyers compared to the US ones [43].

A community recruited controlled study reported that individuals with ICBD had significantly more comorbid major depression and ‘any mood disorder’ than healthy controls [44]. The main link between uncontrolled buying and depression might be low self-esteem. A previous study reported that addictive buyers generally present a significantly lower mean score for self-esteem than normal consumers [18]. A strong and specific relationship between OCD and ICBD has been frequently highlighted and a recent study reported that compulsive buying was more frequent in patients with OCD than in healthy controls [45].

The relationship with eating disorders is unclear: a study found a close relationship between binge eating disorder and compulsive buying [46], but a subsequent study did not report an increased risk for comorbid eating disorder in compulsive buyers [47]. Furthermore, a study, assessing the comorbidity with Axis II disorders in a sample of 46 compulsive buyers on the Structured Interview for DSM-III-R Personality Disorders [48] and a semi-structured interview for buying behaviour, reported that nearly 60% of the sample met criteria for at least one personality disorder: obsessive–compulsive (22%), borderline (15%) and avoidant (15%) personality disorders were the most common [28].

Differential diagnosis

Pathological buying behaviours are not only present within ICBD: these may also be associated with bipolar disorder and OCD (hoarding). However, potential differences in demographics, additional clinical characteristics and buying behaviour between ICBD and other mental disorders have been poorly investigated so far. In clinical practice, symptoms such as elevated mood and the presence of factors unleashing uncontrolled buying should orient the clinician in differentiating ICBD from bipolar disorder. Ultimately, longitudinal aspects within the patient history (i.e. the presence of mood swings) should provide an important clinical indication in order to perform a correct diagnosis. Hoarders should be easy to differentiate based on what they are buying and their tendency to accumulate other things and to have excessive clutter.

Uncontrolled buying may be viewed as the expression of stable factors or state dependent behaviours. The former category would include the presence of impulsive features and personality traits, whereas the state-dependent behaviours would be related to affective instability and mood swings along with the presence of anxiety symptoms [49]. In ICBD, increased purchasing would be associated with arousal or feelings of tension, probably related to stressful life events, whereas in bipolar disorder the uncontrolled purchasing would be an expression of manic or hypomanic episodes. Another difference between patients with affective disorders presenting pathological buying behaviours and subjects with ICBD is the extent of insight that may be lower in manic patients and higher in those with ICBD. Some studies, however, reported that euthymic patients with a lifetime diagnosis of bipolar disorder had a rate of impulsivity higher than healthy controls [49]. Furthermore, a recent study compared the rate of impulsivity in depressed bipolar, depressed unipolar, euthymic bipolar, euthymic unipolar patients and healthy subjects. Depressed bipolar, euthymic bipolar and depressed unipolar patients had a higher impulsivity than healthy controls on the Barratt Impulsiveness Scale (BIS) [50]. Euthymic unipolar patients scored higher than healthy controls only on motor impulsivity [51]. A study reported that depressed compulsive buyers tend to shop alone [30], while a recent study of the same group failed to find statistically significant differences between compulsive buyers and healthy controls [32]: these results may suggest that the tendency to shop alone may be characteristic of depressed subjects presenting compulsive buying, this being a potential element for differential diagnosis. Nevertheless, whether pathological buying behaviours differ in terms of neurobiology remains to be elucidated. Dopamine has been theorized to play a role in behavioural addictions [52], and a recent study investigated the neuroanatomic circuits involved in the decision-making process preceding normal buying. Twenty-six healthy individuals were studied while making buying decisions using event-related functional magnetic resonance imaging; the study found that distinct circuits anticipate gain and loss: product preference activates the nucleus accumbens, while excessive prices activate the insula and deactivate the mesial prefrontal cortex [53]. But further imaging studies are required to obtain a more comprehensive neurobiological characterization of patients with ICBD and clarify differences from healthy controls and other pathological buying behaviours present in different mental disorders.

Clinical symptoms

Patients with ICBD are frequently preoccupied with buying or are subject to irresistible, intrusive and/or senseless impulses to buy. These individuals often purchase unneeded items or more than can be afforded, they buy for periods longer than wanted and experience adverse consequences such as marked distress, impaired social or occupational functioning and financial problems [8].

Compulsive buying disorder is often chronic with brief periods of remission, but it may be episodic for others. Shopping episodes are frequent and not limited to holidays or birthdays [28], [29]; they have the characteristic of urges and typically last 1 h and vary from daily to weekly in occurrence [29]. A previous study reported that 91.7% of individuals with ICBD attempt to resist the urge to buy, but they were often unsuccessful and would make purchase within 1–5 h [17]. In some cases, the impulse arises immediately upon confrontation with a specific stimulus, especially a visual confrontation [17].

Even though individuals with ICBD prefer to shop alone, they buy for themselves as well as for family members and friends, wanting to enhance both others’ and their own image of self [8], [28]. The typical purchases of uncontrolled buying episodes include clothing, shoes, jewellery, cosmetics, DVDs, antiques, household items and books. Men often tend to buy large items (e.g. furniture and stereo equipment) and clothes [29].

A study investigating the type of consequences of compulsive shopping, reported that 58.3% of patients amass large debts, 41.7% are unable to pay their debts, 8.3% run into financial legal problems, 8.3% run into criminal legal problems and 45.8% develop feelings of guilt [29].

Valence et al., trying to identify possible subtypes/phenotypes of compulsive buyers, distinguished four types of consumers: (i) the emotional reactive consumer, who places a certain importance on the symbolism of the article and often presents compensatory and emotional motivations; (ii) the impulsive consumer, who feels a sudden spontaneous desire to buy and lives in a state of possible psychological ambivalence and a struggle between the id and the superego; (iii) the fanatical consumer, who is interested in only one product and is motivated by an enthusiastic and intense devotion; and (iv) the uncontrolled consumer, who tries to reduce psychological tension and sees the act of buying as a way to decrease this tension or anxiety [5].

Treatment strategies

Published guidelines for the treatment of ICBD are lacking and treatment recommendations are mainly based on open-label studies and driven by clinicians’ theoretical orientation. Nevertheless, in recent years both psychotherapy and pharmacological treatments have been shown to be helpful interventions for patients with ICBD [21].

Pharmacological treatment

Considering the hypothesis that ICBD may be an ICD and may be somehow related to OCD, the majority of treatment studies assessed the efficacy of SSRIs. In an open-label study with 20 compulsive buyers, nine subjects had partial or full remission in response to antidepressants, most often SSRIs, usually in combination with mood stabilizers [8]. But subsequent studies have been done with SSRIs without mood stabilizers and no studies of mood stabilizers alone have been published. Given their success with other ICDs such as pathological gambling [54], [55], this is a treatment option that should be investigated.

The effectiveness of fluvoxamine is unclear. An early open-label study reported that nine out of 10 patients improved while receiving fluvoxamine for 9 weeks (mean dosage = 205 mg day⁻¹) [56], but two subsequent double-blind placebo-controlled studies found no difference in efficacy between fluvoxamine and placebo [57], [58]. It seems likely, however, that the use of daily shopping logs by both the fluvoxamine and placebo groups in both studies may have had a therapeutic effect, thus increasing the response in the placebo group and obscuring any difference between the medication treatments [59].

A 12 week open-label trial evaluated the effectiveness of citalopram up to 60 mg day⁻¹ in a sample of 24 subjects with ICBD [60]. Seventeen out of 24 subjects were considered responders, defined as ‘much improved’ or ‘very much improved’ on the Clinical Global Impression-Improvement Scale (CGI-I) [61] and there were three dropouts due to side-effects (sedation and agitation). Afterwards patients were followed through telephone interviews at 3 month intervals for 12 months. Moreover, at the 6 month follow up, subjects maintained on citalopram were less likely to relapse than those discontinuing medication. The effectiveness of citalopram was supported by a subsequent 7 week open-label trial followed by a 9 week, double blind, placebo-controlled discontinuation phase [62]. The sample consisted of 24 patients suffering from ICBD with a score of ≥17 on the Yale–Brown Obsessive Compulsive Scale–Shopping Version (YBOCS-SV). Open-label citalopram was started at 20 mg day^–1 and increased to 60 mg day⁻¹. Patients did not keep a shopping log, as in previous studies, to avoid the potential therapeutic effect of the diary, which limited the confidence in the findings of earlier studies. Response was defined as ratings of ‘much improved’ or ‘very much improved’ on the CGI-I and a ≥50% decrease in YBOCS-SV total score. Fifteen out of 24 patients (63%) were considered responders to the first open phase; three subjects (13%) discontinued due to adverse events. Among the 15 responders who entered the double-blind phase, five out of eight subjects (63%) randomized to placebo had relapses compared with none among the seven subjects randomized to citalopram. Despite the positive results, patients with comorbid depressive disorders had not been excluded and it is possible that the decrease of compulsive shopping might be related to the improvement of depressive symptoms. Moreover, four out of five subjects on placebo who relapsed presented comorbid conditions at baseline: two had a mood disorder (dysthymia and/or major depression) and two had other ICDs (kleptomania and trichotillomania).

A subsequent study reported the results of a 1 year naturalistic follow up of patients with ICBD who had received 3 months of open-label treatment with citalopram at doses from 20 mg day⁻¹ to 60 mg day⁻¹ [59]. The sample presented high psychiatric comorbidity, in particular with depressive disorders and general anxiety disorder. Remission was defined as no longer meeting diagnostic criteria for ICBD according to the McElroy et al. definition [8]. Seventeen out of 24 patients (71%) responded to citalopram and tended to maintain remission after 1 year. The authors then argued that an acute response to citalopram may predict a greater likelihood of continued remission over 1 year.

A more recent 7 week open-label study followed by a 9 week double-blind discontinuation phase did not demonstrate the effectiveness of escitalopram over placebo in the treatment of ICBD [63]. The number of relapses in responders randomized to escitalopram in the second phase was similar to that of the placebo group [63]. Nonetheless, results from studies performed with this specific design in ICDs are not of easy interpretation, as occurred in a recent trial performed with escitalopram in subjects presenting impulsive–compulsive Internet usage disorder, another ICD-NOS [64].

Of clinical interest, two open trials reported positive results with naltrexone, suggesting that opiate antagonists might play a role in the treatment of ICBD [65], [66]. In both studies doses >50 mg day⁻¹ were used. Other opioid antagonists such as nalmefene have not been tested in the treatment of ICBD as yet, but might be valuable because nalmefene has been shown to reduce symptoms in pathological gambling [67].

Psychotherapy

From a psychodynamic perspective, ICBD is thought to involve attempts to regulate the affect and fragmented sense of self and to restore self-object equilibrium, as well as to be a reparative effort to fill internal emptiness [68]. Moreover, compulsive shopping might derive from an inner need for nurturing from the external world [69]. Among the cases reported from two different studies, one patient out of five seems to have experienced unequivocal improvement following psychoanalysis [2], [68].

Some authors suggested the use of desensitization techniques in patients with ICBD [42], and a previous small study supports their effectiveness in two patients [70]. A placebo-controlled study compared group cognitive–behavioural therapy, consisting of 14 meetings over an 8 week period versus placebo, consisting of 11 subjects not randomly assigned to a waiting list control (delayed treatment group), in a sample of patients with ICBD. Twelve out of 28 subjects assigned to active treatment had complete remission during the final 4 weeks and, after 6 months of follow up, 10 participants reported complete 4 week abstinence from compulsive buying episodes [71]. In order to obtain a lasting successful outcome, a therapist should recognize the cues that cause uncontrolled buying and teach patients how to develop appropriate long-term therapeutic strategies for stimulus and impulse control [72].

Finally, some people with ICBD might benefit from self-help books [73] as well as from attending a support group. Debtors Anonymous association provides an atmosphere of mutual support and encouragement for individuals who have accumulated big debts [74].

Conclusions

Interest in ICBD has increased in the last decade, due to the high-prevalence of this mental condition and the social impairment that often results. Biological, social and psychological factors all seem to be important in the aetiology of the disorder, thus an integration of pharmacotherapy and psychotherapy might be the best treatment option, while a specific consideration by future editions of current classification systems and potential treatment algorithms are strongly warranted. As for other ICDs, some clinical trials suggest the efficacy of cognitive–behavioural psychotherapy in reducing impulsive–compulsive symptoms. With regard to pharmacological treatment, emerging data would suggest the effectiveness of SSRIs in the treatment of ICBD and in the prevention of relapses, but further trials are warranted. The future research should investigate the factors that influence the response to the treatment such as the presence of comorbid disorders. Moreover, a better biological knowledge of the neurobiological systems involved in the clinical symptoms of ICBD would allow a more comprehensive understanding of the disorder as well as the development of new and more theoretically based strategies of treatment.

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Impulsive–Compulsive Buying Disorder: Clinical Overview

Abstract

Keywords

Epidemiology

Aetiology

Comorbidity

Differential diagnosis

Clinical symptoms

Treatment strategies

Pharmacological treatment

Psychotherapy

Conclusions

References