Treatment of compulsive buying

Although compulsive buying is receiving increasing attention in research, it is largely ignored in clinical practice. Compulsive buying disorder (CBD) is defined as excessive and mostly senseless spending or excessive shopping impulses that cause marked distress, interfere with social or occupational functioning, and often results in financial problems. It is currently conceptualized as an "impulse control disorder not otherwise specified" (ICD-10 F63.9). CBD is associated with significant psychiatric co-morbidity particularly mood and anxiety disorders, obsessive-compulsive disorders, binge eating disorder, substance use disorders, personality disorders, and other impulse control disorders. Previous research indicates that many compulsive buyers also suffer from compulsive hoarding. There is no evidence-based treatment approach for CBD and treatment research on this topic is limited. Open label trials suggest that antidepressants could improve compulsive buying. However, small randomized controlled trials failed to demonstrate significant improvement over Placebo and the high placebo-response rate prevents any definitive statement on the efficacy of antidepressants. Two controlled cognitive-behavioral therapy (CBT) trials reported that group CBT is significantly more effective compared to waiting list control groups in the treatment of compulsive buying. Clinical and therapeutic implications are discussed.     

Compulsive buying and binge eating disorder--a case vignettes

Compulsive buying behaviour has recently received long overdue attention as a clinical issue. Aim of this report is to describe treatment of two female patients diagnosed with compulsive buying disorder in comorbidity with binge eating disorder. In both cases, criteria for diagnosing of other axis I or axis II disorder were not present. Fluvoxamine was used in pharmacotherapy, and psychodynamic psychotherapy as a psychotherapeutical approach. We conclude that fluvoxamine and psychodynamic psychotherapy may be effective in treatment of compulsive buyers in comorbidity with binge eating disorder.     

Comorbidity in hoarding disorder

Background: Hoarding Disorder (HD) is currently under consideration for inclusion as a distinct disorder in DSM‐5 (1). Few studies have examined comorbidity patterns in people who hoard, and the ones that have suffer from serious methodological shortcomings including drawing from populations already diagnosed with obsessive compulsive disorder (OCD), using outdated definitions of hoarding, and relying on inadequate assessments of hoarding. The present study is the first large‐scale study of comorbidity in a sample of people meeting recently proposed criteria for hoarding disorder (1) and relying on validated assessment procedures. Methods: We compared psychiatric comorbidity in a large HD sample (n = 217) to 96 participants meeting criteria for OCD without HD. Results: High comorbidity rates were observed for major depressive disorder (MDD) as well as acquisition‐related impulse control disorders (compulsive buying, kleptomania, and acquiring free things). Fewer than 20% of HD participants met criteria for OCD, and the rate of OCD in HD was higher for men than women. Rates of MDD and acquisition‐related impulse control disorders were higher among HD than OCD participants. No specific anxiety disorder was more frequent in HD, but social phobia was more frequent among men with HD than among men with OCD. Inattentive ADHD was diagnosed in 28% of HD participants and was significantly more frequent than among OCD participants (3%). Conclusions: These findings form important base rates for developing research and treatments for hoarding disorder. Depression and Anxiety, 2011. © 2011 Wiley‐Liss, Inc.     

Pharmacological treatment of psychiatric comorbidity in bipolar disorder: a review of controlled trials

OBJECTIVE: Little is known about the treatment of psychiatric comorbidities in bipolar disorder. The aim of this review was to summarize the literature on controlled pharmacological trials that have been conducted in psychiatric conditions that commonly co-occur in bipolar disorder. METHODS: A Medline search (1980-October 2005) using the terms bipolar disorder and randomized controlled trials, comorbidity, anxiety disorders, alcohol abuse or dependence, substance abuse or dependence, eating disorder, impulse control disorders, attention-deficit disorder, lithium, anticonvulsants, atypical antipsychotic drugs, antidepressants, stimulants was used. RESULTS: The literature establishes a strong association between bipolar disorder and substance abuse/dependence, anxiety disorders, impulse control disorders, eating disorders and attention-deficit hyperactivity disorder. Comorbidity often complicates the diagnosis and the treatment of bipolar disorder and worsens its course of illness and prognosis. Few controlled pharmacological studies have examined the treatment of comorbid conditions in patients with bipolar disorder. CONCLUSIONS: Treatment of psychiatric comorbidities in bipolar disorder is not based on controlled data but is largely empirically based. Controlled trials in patients with bipolar disorder and comorbidity are urgently needed.     

Study of impulse control disorders among women presenting nicotine dependence

Objective. Impulse control disorders (ICDs) include intermittent explosive disorder, kleptomania, trichotillomania, pyromania and pathological gambling. Several studies have showed an association between ICDs and alcohol use disorders. The rate of co-occurrence ICDs and nicotine dependence has never been investigated. We thus assessed the frequency of all ICDs in a population of nicotine-dependent women compared to non-smoking women. We also checked criteria of two other impulsive behaviours, compulsive buying and bulimia. Methods. Five hundred consecutive patients were assessed by a general practitioner in Paris (France). One hundred and twenty-seven women presenting the DSM-IV-R criteria for nicotine dependence were included. They were compared to 127 women consulting the same practitioner but who did not smoke. Diagnosis of ICD (pyromania, kleptomania, trichotillomania, intermittent explosive disorder, pathological gambling) and of bulimia was based on DSM-IV criteria and a modified version of the Minnesota Impulsive Disorders Interview (MIDI). Diagnosis of compulsive buying was made with the McElroy et al. criteria and a specific questionnaire. Cigarette smoking was studied using the Fagerström questionnaire and the DSM-IV-R criteria for nicotine dependence. Alcohol use disorders were assessed with the DSM-IV-R criteria for dependence and the CAGE and the MAST questionnaires. Results. Thirteen patients presented trichotillomania, 22 explosive intermittent disorder and 12 pathological gambling. All these diagnoses were equally frequent in the nicotine-positive and nicotine-negative groups. We found no case of pyromania. Compulsive buying was the most frequent impulse control disorder. It was significantly more frequent in the nicotine-positive group than in the nicotine-negative group (58 vs. 39 cases, P=0.01). Scores of the compulsive buying scale were higher in the nicotine-positive group (4.07 vs. 2.9, P=0.01). None of the patients presented an association of two or more ICDs. Patients from the nicotine-positive group drunk higher quantities of alcohol each day, consumed alcohol more frequently each week and were more often intoxicated each week with alcohol. Their mean MAST scores of alcohol abuse disorders were higher. Conclusion. A total of 45.6% of the nicotine-dependent women presented compulsive buying and 23.6% bulimia. Compulsive buying was significantly more frequent among nicotine-dependent subjects than controls. Other impulse control disorders were as frequent among nicotine-dependent women as in controls. A total of 8.6% presented explosive intermittent disorder, 4.7% pathological gambling and 5% trichotillomania. Nicotine dependence in women was also associated with a higher level of alcohol consumption. These results indicate the possible need to systematically screen nicotine-dependent women, regardless of their motivation for consultation, for alcohol dependence, bulimia and compulsive buying.     

Self-reported and neuropsychological measures of impulsivity in pathological gambling.

Pathological Gambling is an impulse control disorder. Impulsivity has been investigated separately by neuropsychological tests and self-report scales. Although some studies have tried to correlate these approaches, their interaction has not been sufficiently explored among pathological gamblers (PG). In this study, we have compared 214 PG (162 with comorbidity and 52 with no comorbidity) to 82 healthy volunteers regarding the reaction time and number of errors at Go/No-go tasks, and scores on the Barratt Impulsiveness Scale (BIS). PG have committed more errors at the Go/No-go tasks and presented higher scores on the self-report scale. The neuropsychological tests and BIS composed a multinomial logistic model that discriminated PG from non-gamblers better than models having one or another type of measure. Impulsivity seems to be a multi-dimensional phenomenon, and PG a heterogeneous population in which different types of impulsivity are present.     

Oniomania--successful treatment with fluvoxamine and cognitive-behavioral psychotherapy

Compulsive buying (oniomania) is a disorder that has begun to receive attention from researchers in recent years. It has been estimated that disorder affects from 2 to 8% of the general adult population in the US (official data for Croatia are not available). About 90% of those affected are female. Onset occurs in the late teens or early twenties, and the disorder is generally chronic. Psychiatric comorbidity is frequent, particularly mood, anxiety, substance use, eating and personality disorders. Treatment has not been well delineated, but individual and group psychodynamic psychotherapy, cognitive-behavioural therapy and 12-step programmes may be helpful. Serotonin (5-hydroxytryptamine; 5-HT) re-uptake inhibitors may help some patients regulate their buying impulses. We have presented the case of a 32-year old woman with a history of excessive pathological buying treated successfully with combined therapy (fluvoxamine and cognitive-behavioral psychotherapy).     

Pediatric Trichotillomania

Trichotillomania (TTM) is an impulse control disorder characterized by chronic hair-pulling, distress, and impairment. Although the negative effects of TTM are documented and often readily evident, there remains a paucity of psychopathology and treatment research on this disorder, particularly in pediatric populations. In an effort to improve assessment of pediatric TTM, several TTM-specific instruments for youth have now been developed to reliably identify symptoms and examine related phenomenology. Instrument development has now yielded instruments to evaluate TTM and related symptoms in the context of clinical trials of youth, and the first randomized controlled trial of any treatment for pediatric TTM was recently published. Using the initial pediatric TTM studies as building blocks, future research is now needed to create a stronger body of knowledge about the relative and combined efficacy of potential interventions for TTM in youth, as well as to examine the effects of TTM phenomenology and comorbidity on treatment outcome. Dissemination efforts must also be heightened for this knowledge to best reach these vulnerable populations.     

Impulse control disorders in adult psychiatric inpatients

OBJECTIVE: The authors' goal was to examine the prevalence of impulse control disorders in psychiatric inpatients. METHOD: They used the Minnesota Impulsive Disorders Interview, a semistructured clinical interview assessing pathological gambling, trichotillomania, kleptomania, pyromania, intermittent explosive disorder, compulsive buying, and compulsive sexual behavior, to screen 204 consecutively admitted psychiatric inpatients. One hundred twelve of the inpatients were women (54.9%), and the mean age of the 204 inpatients was 40.5 years (SD=13.2, range=18-83). Patients whose screen was positive for an impulse control disorder were evaluated with structured clinical interviews. RESULTS: Sixty-three patients (30.9%) were diagnosed with at least one current impulse control disorder. The most common impulse control disorders were compulsive buying (N=19 [9.3%]), kleptomania (N=16 [7.8%]), and pathological gambling (N=14 [6.9%]). Patients with and without co-occurring impulse control disorders did not differ significantly from each other on demographic measures or number or type of psychiatric diagnoses other than impulse control disorders. CONCLUSIONS: Impulse control disorders appear common among psychiatric inpatients. Additional, larger studies are needed to examine the prevalence of impulse control disorders in the general population and specific psychiatric groups.     

Impulse control disorders in women with eating disorders

We compared symptom patterns, severity of illness, and comorbidity in individuals with eating disorders with and without impulse control disorders (ICD), and documented the temporal pattern of illness onset. Lifetime ICD were present in 16.6% of 709 women with a history of eating disorders. The most common syndromes were compulsive buying disorder and kleptomania. ICD occurred more in individuals with binge eating subtypes, and were associated with significantly greater use of laxatives, diuretics, appetite suppressants and fasting, and with greater body image disturbance, higher harm avoidance, neuroticism, cognitive impulsivity, and lower self-directedness. In addition, individuals with ICD were more likely to have obsessive-compulsive disorder, any anxiety disorder, specific phobia, depression, cluster B personality disorder, avoidant personality disorder, and to use psychoactive substances. Among those with ICD, 62% reported the ICD predated the eating disorder and 45% reported the onset of both disorders within the same 3-year window. The presence of a lifetime ICD appears to be limited to eating disorders marked by binge eating and to be associated with worse eating-related psychopathology, more pathological personality traits, and more frequent comorbid Axis I and II conditions. Untreated ICD may complicate recovery from eating disorders.     

Chronic depression and comorbid personality disorders: response to sertraline versus imipramine

BACKGROUND: Chronic subtypes of depression appear to be associated with high rates of Axis II personality disorder comorbidity. Few studies, though, have systematically examined the clinical correlates of Axis II personality disorder comorbidity or its effect on treatment response or time to response. METHOD: 635 patients diagnosed with DSM-III-R chronic major depression or "double depression" (dysthymia with concurrent major depression) were randomized to 12 weeks of double-blind treatment with either sertraline or imipramine between February 1993 and December 1994. Axis II diagnoses were made using the personality disorders version of the DSM-III-R Structured Clinical Interview. The effect of study treatment was measured utilizing the Hamilton Rating Scale for Depression and the Clinical Global Impressions scale. RESULTS: Forty-six percent of patients met criteria for at least 1 comorbid Axis II personality disorder, with cluster C diagnoses being the most frequent at 39%; 21% met criteria for at least 2 Axis II personality disorders. A cluster C diagnosis was associated with significantly higher rates of early-onset depression (before age 21; 47% vs. 32% for no cluster C; p =.005) and comorbid anxiety disorder (34% vs. 18% for no cluster C; p <.001). Overall, the presence of Axis II personality disorder comorbidity had minimal-to-no effect on the ability to achieve either an antidepressant response or remission and had inconsistent effects on time to response. The presence of Axis II personality disorder comorbidity did not appear to reduce functional and quality-of-life improvements among patients responding to acute treatment with sertraline or imipramine. CONCLUSION: In this treatment sample, rates of Axis II personality disorder comorbidity were substantial in patients suffering from chronic forms of depression. Axis II personality disorder comorbidity did not appear to diminish symptomatic response to acute treatment or associated improvement in functioning and quality of life.     

Impulsive-compulsive buying disorder: clinical overview

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.     

Neither bipolar nor obsessive-compulsive disorder: compulsive buyers are impulsive acquirers

IntroductionCompulsive buying (CB) is currently classified as an impulse control disorder (ICD) not otherwise classified. Compulsive buying prevalence is estimated at around 5% of the general population. There is controversy about whether CB should be classified as an ICD, a subsyndromal bipolar disorder (BD), or an obsessive-compulsive disorder (OCD) akin to a hoarding syndrome. To further investigate the appropriate classification of CB, we compared patients with CB, BD, and OCD for impulsivity, affective instability, hoarding, and other OCD symptoms.MethodEighty outpatients (24 CB, 21 BD, and 35 OCD) who were neither manic nor hypomanic were asked to fill out self-report questionnaires.ResultsCompulsive buying patients scored significantly higher on all impulsivity measures and on acquisition but not on the hoarding subdimensions of clutter and “difficulty discarding.” Patients with BD scored higher on the mania dimension from the Structured Clinical Interview for Mood Spectrum scale. Patients with OCD scored higher on obsessive-compulsive symptoms and, particularly, higher on the contamination/washing and checking dimensions from the Padua Inventory; however, they did not score higher on any hoarding dimension. A discriminant model built with these variables correctly classified patients with CB (79%), BD (71%), and OCD (77%).ConclusionPatients with CB came out as impulsive acquirers, resembling ICD- rather than BD- or OCD-related disorders. Manic symptoms were distinctive of patients with BD. Hoarding symptoms other than acquisition were not particularly associated with any diagnostic group.     

Ludomania: cross-cultural examinations of gambling and its treatment

Pathological gambling is a disorder of impulse control that is gaining more and more attention. This paper reviews diagnostic criteria and screening instruments for pathological gambling, as well as the prevalence rates of this disorder worldwide, with an emphasis on gambling in Brazil. Treatments for pathological gambling are also described, including both psychosocial and pharmacological approaches. Pathological gambling is highly comorbid with other psychiatric disorders, including substance abuse and depression, and few pathological gamblers seek treatment for their gambling problems. Therefore, direct screening for gambling problems is recommended. Increasing education about the disorder, from both the provider and societal perspective, is necessary to reduce the personal and societal consequences of this disorder.     

Personality disorders in somatization disorder patients: a controlled study in Spain

OBJECTIVE: The aim of this paper is to assess personality disorder (PD) comorbidity in somatization disorder (SD) patients compared with psychiatric controls in a Spanish sample. METHODS: This is a case-control study. Selection of 70 consecutive SD patients was made, and an age-, sex-, and ethnic-group-matched control group of 70 mood and/or anxiety disorder patients recruited in psychiatric outpatient clinics was selected. PDs were measured using the International Personality Disorder Examination, and Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition Axis I morbidity was measured by means of the Standardized Polyvalent Psychiatric Interview. RESULTS: PD comorbidity in SD patients was 62.9%, compared to 28.2% in controls [odds ratio (OR)=3.7; 95% confidence interval (95% CI)=1.8-7.6]. The highest ORs of PD in SD patients, compared with controls, were for paranoid (OR=9.2; 95% CI=1.9-43), obsessive-compulsive (OR=6.2; 95% CI=1.2-53.6), and histrionic (OR=3.6; 95% CI=0.9-13.9) PDs. CONCLUSIONS: This is a controlled study with the largest sample of SD patients. The prevalence of PD comorbidity is similar to that of a previously published controlled study but is different from those of the most frequent PD subtypes.     

Update on pathological skin picking

Pathological skin picking (PSP) is a disabling disorder characterized by repetitive picking of the skin that causes tissue damage. Estimated to affect 2% to 5.4% of the population, PSP is currently listed as an impulse control disorder not otherwise specified. However, the repetitive and compulsive behaviors seen in PSP are phenomenologically and clinically similar to the behaviors seen in obsessive-compulsive disorder and other body-focused repetitive behaviors, such as trichotillomania and pathological nail biting. Animal neuroimaging research in related disorders such as obsessive-compulsive disorder and trichotillomania provides useful information for understanding PSP. Recent cognitive testing of individuals with PSP demonstrated impaired inhibitory control; these findings may assist in the proper characterization of PSP and aid in the development of effective treatment options. Although the disorder is common, appropriate treatments for PSP are limited. Pharmacotherapeutic and certain cognitive-behavioral interventions have demonstrated promise in treating this disorder and need to be explored further.     

Obsessive-compulsive disorder and body dysmorphic disorder: a comparison of clinical features.

Body dysmorphic disorder (BDD) is currently classified as a somatoform disorder in DSM-IV, but has been long noted to have some important similarities with obsessive-compulsive disorder (OCD). In addition, BDD and OCD have been often reported to be comorbid with each other. In the present study, we compared demographic characteristics, clinical features and psychiatric comorbidity in patients with OCD, BDD or comorbid BDD-OCD (34 subjects with BDD, 79 with OCD and 24 with BDD-OCD). We also compared the pattern of body dysmorphic concerns and associated behaviors in BDD patients with or without OCD comorbidity. In our sample, BDD and OCD groups showed similar sex ratio. Both groups with BDD and BDD-OCD were significantly younger, and experienced the onset of their disorder at a significantly younger age than subjects with OCD. The two BDD groups were also less likely to be married, and more likely to be unemployed and to have achieved lower level degree, than OCD subjects even when controlling for age. The three groups were significantly different in the presence of comorbid bulimia, alcohol-related and substance-use disorders, BDD-OCD patients showing the highest rate and OCD the lowest. BDD-OCD reported more comorbid bipolar II disorder and social phobia than in the other two groups, while generalized anxiety disorder was observed more frequently in OCD patients. Patients with BDD and BDD-OCD were similar as regards the presence of repetitive BDD-related behaviors, such as mirror-checking or camouflaging. Both groups also did show a similar pattern of distribution as regards the localization of the supposed physical defects in specific areas of the body. The only significant difference concerned the localization in the face, that was more frequent in the BDD group. Our results do not contradict the proposed possible conceptualization of BDD as an OCD spectrum disorder. However, BDD does not appear to be a simple clinical variant of OCD and it seems to be also related to social phobia, mood, eating and impulse control disorders. The co-presence of BDD and OCD features appears to possibly individuate a particularly severe form of the syndrome, with a greater load of psychopathology and functional impairment and a more frequent occurrence of other comorbid mental disorders.     

Pharmacotherapy of pathological gambling: review of new treatment modalities

Pathological gambling is classified in the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition as an impulse-control disorder. In the International Classification of Diseases of the WHO, pathological gambling is coded under the heading of 'Habit and Impulse Disorders'. Pathological gambling is a chronic, progressive disorder, which has a prevalence of 1-3.4% among western civilizations. The enormous personal and social consequences of this disorder include a high rate of suicide attempts, job loss, marital and family problems, legal problems, and criminal behavior. Recent studies have demonstrated that pathological gambling patients respond well to treatment with selective serotonin reuptake inhibitors, mood stabilizers and opioid antagonists. These findings support the idea that pathological gambling and other disorders of impulse control may be conceptualized as part of the obsessive-compulsive spectrum disorders or addictive disorders. This article will discuss possible treatment strategies according to different behavior patterns in pathological gambling and also remind the physicians who intend to treat this disorder of the possible diagnosis of pathological gambling.     

Kaufsucht – Aktuelle Überlegungen zur Klassifikation und Therapie

Compulsive shopping is classified by ICD-10 (F63.8) as an "impulse control disorder, not otherwise classified". Several authors consider compulsive shopping rather as a variety of dependence disorder. It is characterized by the impulsive or compulsive buying of unneeded things, personal distress, impaired social and vocational functioning, and/or financial problems. In this case, we discuss a two-way therapy consisting of addiction-specific psychological education and high dose selective serotonin reuptake inhibitors (SSRIs). We further point to compliance problems caused by SSRI side effects.     

Comparing anxiety disorders and anxiety-related traits in bipolar disorder and unipolar depression

The frequent comorbidity of anxiety disorders and mood disorders has been documented in previous studies. However, it remains unclear whether specific anxiety traits or disorders are more closely associated with unipolar major depression (MDD) or bipolar disorder (BPD). We sought to examine whether MDD and BPD can be distinguished by their association with specific types of anxiety comorbidity. Individuals with a primary lifetime diagnosis of either bipolar disorder (N=122) or major depressive disorder (N=114) received diagnostic assessments of anxiety disorder comorbidity, and completed questionnaires assessing anxiety sensitivity and neuroticism. The differential association of these anxiety phenotypes with MDD versus BPD was examined with multivariate modeling. Panic disorder and generalized anxiety disorder (GAD) specifically emerged amongst all the anxiety disorders as significantly more common in patients with BPD than MDD. After controlling for current mood state, anxiety sensitivity and neuroticism did not differ by mood disorder type. This study supports prior research suggesting a specific panic disorder-bipolar disorder connection, and suggests GAD may also be differentially associated with BPD. Further research is needed to clarify the etiologic basis of anxiety disorder/BPD comorbidity and to optimize treatment strategies for patients with these co-occurring disorders.