The article in this issue by Koran et al. raises several intriguing questions regarding a novel proposed psychiatric disorder: compulsive buying. DSM provides a working model of categories and diagnostic criteria for psychiatric disorders. DSM is constantly evolving and research planning is underway for DSM-V. Changes to DSM-V being considered include the creation of two broad new categories that may influence the conceptualization of compulsive buying.
A category related to obsessive-compulsive-related disorders might include disorders such as obsessive compulsive disorder, obsessive compulsive personality disorder, hoarding, body dysmorphic disorder, eating disorders, hypochondriasis, Tourette’s syndrome, Sydenham’s chorea or pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections, and pathological grooming disorders, such as trichotillomania, skin picking, and nail biting. Compulsive buying was not determined to be a good fit for this category. On the other hand, a parallel category under consideration is behavioral and substance addictions, which might include substance-related disorders and several impulse-control disorders (pathological gambling, pyromania, and kleptomania), as well as others currently in the category of impulse control disorders not otherwise specified (Internet addiction, impulsive-compulsive sexual behavior, and compulsive buying). The National Institute on Drug Abuse has considered behavioral addictions (such as compulsive buying) to be “cleaner” and more homogeneous models of substance addictions because these conditions may share clinical features and perhaps underlying brain circuitry, and these features and circuitry are not altered by the ingestion of exogenous substances. Similar phases seem to occur for behavioral and substance addictions: initially, episodes are characterized by increasing physiological and emotional arousal before the act; pleasure, high, or gratification associated with the act; and a decrease in arousal and feelings of guilt and remorse afterward. Tolerance and physiological withdrawal can also develop. Because an impulsive component (pleasure, arousal, or gratification) is involved in initiating the cycle, and a compulsive component is involved in the persistence of the behavior, these conditions may also be thought of as impulsive-compulsive disorders.
The creation of a condition such as compulsive buying might be associated with controversy and criticized by some as creating a trivial disorder; “medicalizing” a “moral” problem or creating a new disorder in order to sell more pharmaceuticals. Similar criticisms of attention deficit hyperactivity disorder (ADHD) and social anxiety disorder have been raised: that children with minor and natural levels of excess activity should not be “medicalized” or medicated or that because so many people are socially anxious, this is a natural trait not worthy of diagnosis or treatment. However, the issues involved in creating new diagnoses is complex.
In this issue, Koran et al. reported on a study of compulsive buying. They surveyed a large random sample of U.S. adults to estimate a prevalence rate and to characterize compulsive buyers. They and others have proposed names and diagnostic criteria for this problem and, as required for most DSM disorders, the criteria include significant distress or functional impairment, as well as criteria specific to the disorder. As is typical at this stage, the specific name and criteria differ from researcher to researcher and study to study, complicating the development of knowledge about the condition. Until a certain amount of evidence of a new disorder is accumulated, not enough is known to define criteria, but at a certain point, there is enough information to propose criteria. Including a disorder in DSM is very helpful for the advance of knowledge because researchers can then use the defined criteria in their new research, and the criteria can be refined over time as more research is completed.
Clearly, the behavioral addictions or impulse control disorders can be viewed from different perspectives, including: a medical perspective; a moral, ethical, or religious perspective; and a legal perspective. These behaviors exist on a continuum, perhaps in a normal distribution in the general population, with many individuals having some of the behaviors, a few showing none, and a few showing a great deal. However, in a subgroup of individuals, a biological vulnerability may result in impairment of control that leads to behavioral excess or disinhibition and is associated with significant levels of distress and functional impairment. Consideration that shopping is universal and making an unwise purchase from time to time is common, although research has shown that there are individuals whose compulsive buying is extreme and leads to significant distress and impairment. Using scores on the Compulsive Buying Scale (1) of 2 standard deviations below the mean, Koran et al. estimated the prevalence of compulsive buying to be 5.8%; even with a very strict criterion of 3 standard deviations below the mean, the prevalence would be 1.4%. Previous estimates based on smaller, less representative samples have ranged from 1.8% to 16%. Thus, whatever estimate is used, the prevalence is higher than or similar to disorders that receive considerable research and clinical attention, and it represents a sizable group suffering distress and or functional impairment. The impairment criteria are important because it is how compulsive buying as a disorder is differentiated from more normal, if excessive, buying. Koran et al. found that when using the criterion of 2 standard deviations on the Compulsive Buying Scale, the individuals had significantly more maladaptive shopping and buying attitudes and behaviors and more financial problems than the other respondents. The data for the group with 3 standard deviations shows consequences that were even more extreme. This sort of distribution applies to many disorders. As mentioned above, ADHD and social anxiety disorder are two examples. One might also look at a long-accepted disorder: major depressive disorder. Many people suffer from occasional sadness and days on which they are “blue,” but that does not diminish the importance of recognizing, researching, and treating major depressive disorder.
One can ask if people are morally responsible for their behavior if they commit unethical acts because of what has been classified as a mental disorder? Similarly, if an individual diagnosed with an impulse control disorder does something illegal, is he or she responsible? Having a diagnosable disorder does not eliminate the moral or legal consequences of bad behavior, although courts can require that the individuals receive treatment in order to prevent a recurrence of the problem. This can be seen with alcoholism, which has long been considered a disorder. If an alcoholic has an accident while driving under the influence, that is not considered a mitigating circumstance but the courts can require that the individual undergo treatment for their alcohol problem, along with any other sentencing requirements. Viewing compulsive buying from a medical perspective and as a diagnosable mental disorder has several advantages. It might facilitate routine screening for the condition by mental health professionals, and perhaps, even inclusion of the disorder in national prevalence surveys, which would help define the true prevalence of the disorder. It might also lead to the study of vulnerability factors for the development of the disorder, better characterization of brain-based circuits, and the development of effective psychosocial and medication treatments. Although prevention of overdiagnosis or possible misuse of diagnostic labels is important, these concerns should be balanced against the advancement of knowledge that could potentially lead to new treatments or prevention strategies for serious human problems.
1.Faber RJ, O’Guinn TC: A clinical screener for compulsive buying. J Consumer Res 1992; 19:459–469
Address correspondence and reprint requests to Dr. Hollander, Department of Psychiatry, Mt. Sinai School of Medicine, One Gustave L Levy Place, New York, NY 10029; firstname.lastname@example.org (e-mail.) Dr. Hollander has been a consultant to Ortho-McNeil, Abbott, and Forest; and has received research grants from NIMH, NIDA, NINDS, and OPD-FDA. Dr. Freedman has reviewed this editorial and found no evidence of influence from these relationships. Dr. Allen reports no competing interests.