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Is Compulsive Buying a Real Disorder, and Is It Really Compulsive?

Article  in  American Journal of Psychiatry · November 2006

DOI: 10.1176/appi.ajp.163.10.1670 · Source: PubMed

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 Editorial

Is Compulsive Buying a Real Disorder,

and Is It Really Compulsive?

T he 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 con-
sidered include the creation of two broad new categories that may influence the con-
ceptualization 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 syn-
drome, Sydenham’s chorea or pediatric autoim-
mune neuropsychiatric disorders associated
“Changes to DSM-V being with streptococcal infections, and pathological
considered include the grooming disorders, such as trichotillomania,
skin picking, and nail biting. Compulsive buying
creation of two broad was not determined to be a good fit for this cate-
new categories that gory. On the other hand, a parallel category un-
may influence the der consideration is behavioral and substance
addictions, which might include substance-re-
conceptualization of lated disorders and several impulse-control dis-
compulsive buying.” orders (pathological gambling, pyromania, and
kleptomania), as well as others currently in the
category of impulse control disorders not other-
wise specified (Internet addiction, impulsive-compulsive sexual behavior, and compul-
sive buying). The National Institute on Drug Abuse has considered behavioral addic-
tions (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 inges-
tion of exogenous substances. Similar phases seem to occur for behavioral and sub-
stance 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 con-
troversy 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 criti-
cisms 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

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 EDITORIAL

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 re-
searchers 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 sub-
group 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 mak-
ing 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 at-
tention, and it represents a sizable group suffering distress and or functional impair-
ment. 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 be-
haviors 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 so-
cial 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, re-
searching, and treating major depressive disorder.
One can ask if people are morally responsible for their behavior if they commit uneth-
ical acts because of what has been classified as a mental disorder? Similarly, if an indi-
vidual 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 con-
sequences 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 alco-
holism, 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 vulner-
ability factors for the development of the disorder, better characterization of brain-
based circuits, and the development of effective psychosocial and medication treat-
ments. Although prevention of overdiagnosis or possible misuse of diagnostic labels is

Am J Psychiatry 163:10, October 2006 ajp.psychiatryonline.org 1671

 EDITORIAL

important, these concerns should be balanced against the advancement of knowledge

that could potentially lead to new treatments or prevention strategies for serious hu-
man problems.

Reference
1. Faber RJ, O’Guinn TC: A clinical screener for compulsive buying. J Consumer Res 1992; 19:459–469

ERIC HOLLANDER, M.D.

ANDREA ALLEN, PH.D.

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; eric.hollander@mssm.edu (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.

1672 ajp.psychiatryonline.org Am J Psychiatry 163:10, October 2006

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