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Section 11
Compulsive Buying Disorder Part IV: Clinical Management

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Clinical Management
There is no standard approach to the treatment of compulsive buying disorder. Treatment recommendations, for the most part, are empirically based, and are driven by the theoretical orientation of the clinician. For example, those who view compulsive buying as an addiction base their recommendations on treatment models originally developed for substance use disorders. The following discussion summarizes the therapeutic approaches that have been reported in the literature.

Psychoanalysts have suggested that psychodynamic issues may be central to initiating and maintaining the disorder in some cases. Krueger[7] presented 4 cases to demonstrate that compulsive buying involved ‘attempts to regulate the affect and fragmented sense of self and to restore self object equilibrium’, as well as a reparative effort to fill internal emptiness. Winestine[9] presented a case in which psychodynamic issues included past sexual abuse and fantasies of being the wife of a famous millionaire who had the power and funds to afford her anything she wished. Winestine[9] felt that in identifying with this role, the patient reversed her actual feelings of helplessness in yielding to shop and spend: ‘The purchases offered some momentary fortification against her feelings of humiliation and worthlessness for being out of control’. Lawrence[8] felt that compulsive shopping stems from an inner need for nurturing from the external world.

Of the 5 cases reported by Krueger[4] and Winestine,[ 9] only one patient appears to have experienced unequivocal improvement following psychoanalysis.

Cognitive-Behavioral Therapy
Cognitive and behavioral therapies are being developed, but data regarding efficacy are limited. Lejoyeux et al.[35] suggests the use of graded exposure to evermore tempting situations paired with response prevention, and instruction in techniques of impulse and conditioned stimulus control. Bernik et al.[29] described 2 patients with comorbid panic disorder and agoraphobia responsive to clomipramine, whose compulsive buying was unaffected by the drug. Each patient responded well to the 3 to 4 weeks of daily exposure to shopping stimuli with response prevention, at first by an accompanying individual and later by themselves. Follow-up data were not presented.

Group cognitive-behavioral therapy has been described by Burgard and Mitchell,[36] consisting of 14 meetings over an 8-week period. The therapy focuses on factors that maintain the problematic buying behavior, and on strategies for controlling impulsive spending and not on the individual group member’s personal problems. (Most of the treatment concepts were taken directly from group therapy models developed for individuals with other types of compulsive behaviors, such as bulimia nervosa.) In a preliminary study of 8 women, each experienced substantial improvement. The authors report that their findings are encouraging, and suggest that further work be done using this treatment model.

McElroy et al.[15] reported the cases of 3 women who all appeared to demonstrate partial or complete remission of compulsive buying behavior with fluoxetine, amfebutamone (bupropion) or nortriptyline. All had concurrent mood and anxiety disorders. The authors concluded from these cases that antidepressant therapy may benefit individuals with compulsive shopping. In a subsequent study, McElroy and colleagues[16] reported on a series of 20 patients, 9 of whom had partial or full remission in response to trials of antidepressants, most often serotonin reuptake inhibitors, usually in combination with mood stabilisers. In most cases, the observation period was limited to a few months. Two of the 9 patients who improved had received supportive or insight-oriented therapy before receiving drug treatment.

Lejoyeux et al.[37] reported on 2 patients with major depression and compulsive buying; in each case, the treatment of the mental disorder led to the resolution of the compulsive buying behavior. In one patient, clomipramine was used (150 mg/day); in the other, no drug was specified. These authors suggest that antidepressant treatment is successful when uncontrolled spending is associated with depression.

Black et al.[38] reported that 9 of 10 individuals with compulsive buying who were recruited through newspaper advertisement improved while receiving fluvoxamine. The study lasted 9 weeks, and patients achieved a mean dosage of 205 mg/day. Three patients improved during the first week, and all had responded by week 5. Study participants were followed for an additional 4 weeks; by that time, 7 of the 10 patients requested continuation therapy. The authors reported that those who improved were less preoccupied with shopping, spent less time shopping and reported spending less money. The fact that none of the patients had major depression appeared to refute the assertion of Lejoyeux et al.[37] that depressed individuals with compulsive buying disorder are more likely to improve with antidepressants than those who are not depressed.

Two subsequent double-blind placebo-controlled trials have been conducted.[28,39] In a study by Black and colleagues,[39] 12 patients were randomly assigned to fluvoxamine and 11 to placebo for a 9-week study. None were depressed. At the conclusion of the trial, 50% of fluvoxamine recipients and 64% of placebo recipients were rated as ‘much’ or ‘very much’ improved. Patients in both treatment cells showed improvement as early as the second week of the trial and, for most, improvement continued during the 9-week study. There were no significant differences between fluvoxamine- and placebo-treated patients on any of the main outcome measures using an intent-to-treat analysis. Mean YBOCS-SV scores of the fluvoxamine-treated individuals fell from 21 at baseline to 15 at week 9, and for the placebo recipients from 24 at baseline to 14 at the end of week 9. Improvement measured from baseline to week 9 was statistically significant for both fluvoxamine and placebo recipients. This report strongly suggests that compulsive buying disorder may have a high placebo response rate, which needs to be taken into account in subsequent studies. The case of a woman enrolled in the study is presented in table VI.

Ninan et al.[28] reported the results of another double-blind 12-week trial comparing fluvoxamine with placebo in 37 patients with compulsive buying disorder treated at 2 sites. An intent-to-treat analysis failed to show a significant difference between fluvoxamine and placebo recipients using a version of the YBOCS or the Clinical Global Improvement (CGI) scale.

Another study is underway to test the efficacy of citalopram in compulsive buying disorder. Koran will enroll 24 individuals in a 12-week open label trial; if results are positive, he will then initiate a double-blind, placebo-controlled trial (L. Koran, personal communication).

Finally, in a single case report Kim[40] described improvement in a woman with a 5-year history of compulsive buying who was treated with naloxone, an opioid antagonist. He noted that he had observed 3 additional cases where naloxone produced improvement.

Other Approaches
Relatively few individuals with compulsive buying disorder seek psychiatric treatment. Because many view the disorder as financial, rather than medical or psychiatric, those affected may seek counseling more often from bankers or financial consultants than from mental health professionals.[ 41,42] There are no data on the extent of this form of counseling, but such advice may be helpful. Many compulsive shoppers can benefit from attending a support group. Debtors Anonymous, patterned after Alcoholics Anonymous, provides an atmosphere of mutual support and encouragement for individuals who have accumulated substantial debts.[43]

Self-help books are also available, including Shopaholics – Serious Help for Addicted Spenders,[ 44] Born to Spend – How to Overcome Compulsive Spending,[45] and Women Who Shop too Much – Overcoming the Urge to Splurge.[46] Each book provides sensible recommendations that individuals who exhibit compulsive buying can employ to gain control over their inappropriate shopping and spending behavior.

Compulsive buying disorder appears to be widespread, to preferentially affect women, and to have an age of onset in the late teens or early twenties. Psychiatric comorbidity is common, particularly with mood, anxiety and substance use disorder. Axis II disorders are also relatively common.

There has been little consensus on treatment, but individual and group psychotherapy, cognitive-behavioral therapy, and 12-step programs may be helpful. Serotonin reuptake inhibitors may help patients to regulate their buying impulses.

More work is needed to determine the prevalence and risk factors for compulsive buying disorder. Intensive studies of individuals with compulsive buying disorder using standardized and reliable instruments can help establish its course, psychiatric comorbidity and complications. Greater knowledge of compulsive buying will help clinicians to develop more specific and effective therapies.
- Black, DW; Compulsive buying disorder: definition, assessment, epidemiology; and clinical management; CNS Drugs; 2001; Vol. 15; Issue 1.

Personal Reflection Exercise #4
The preceding section contained information about the clinical management of compulsive buying disorder. Write three case study examples regarding how you might use the content of this section in your practice.

Online Continuing Education QUESTION 11
What is the focus of group cognitive-behavioral therapy described by Burgard and Mitchell? To select and enter your answer go to CEU Test.

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