John M. Kuzma, MD

Ms. A has been compulsively shopping and spending since age 19 when she first obtained credit cards. After years of intense urges to shop and remorse over the financial consequences, she seeks psychiatric help. Now age 37 and divorced, she has controlled her spending only for two 1- to 2-year periods that coincided with bankruptcy proceedings.

With easy access to credit, many persons such as Ms. A develop what is variously called compulsive buying, compulsive shopping, addictive shopping, or shopaholism. Although “medicalizing” excessive shopping may seem to obscure its broader cultural and social causes,¹ increasing evidence points to a discrete shopping disorder.

Our group has contributed to compulsive buying research and continues to evaluate potential treatments. We offer evidence and practical advice to help you:

• identify compulsive shopping disorder using the patient’s history and three screening questions
  
• differentiate compulsive shopping from manic or hypomanic shopping sprees
  
• educate patients about four steps to control compulsive shopping.
  

Table 1

Compulsive shopping disorder’s clinical signs

Onset in late adolescence to early adulthood
Female-to-male ratio may be 9:1
Behaviors include shopping frequently, spending inappropriately, and fantasizing about future purchases
Psychiatric comorbidity—mood disorders, substance abuse, eating disorders—is common among patients and first-degree relatives
Chronic symptoms wax and wane, with widely varying severity
Irresistible urges prompt spending by some patients
Shopping is intensely exciting, with transitory feelings of happiness and power
Feelings of distress and guilt develop after shopping; patients often hide purchases
Patients may be in denial or feel embarrassed to disclose symptoms

An Evolving Picture

Ms. A says shopping is her primary social activity and entertainment. Though she works full time, she shops three or more times a week, cruising expensive department stores and discount outlets on evenings and weekends. She buys clothing, shoes, makeup, jewelry, antiques, household electronics, and other items.

She says her shopping is spontaneous and impulsive. Shopping gives her an emotional “rush” that is frequently followed by periods of guilt, and she often returns or gives away purchased items. She is disappointed at her inability to control her shopping behavior and ashamed of the financial crises she has caused.

Compulsive buying is characterized by persistent or poorly controlled preoccupations, urges, or behaviors regarding shopping or spending, leading to adverse consequences.² Onset in late adolescence to early adulthood is the usual pattern, and the disorder is thought to be chronic or recurrent. It is not listed in DSM-IV-TR but is considered an example of an impulse control disorder not otherwise specified. For this paper, we use the terms compulsive shopping and compulsive buying interchangeably.

The disorder’s tentative classification reflects debate about its conceptualization. Some clinicians and researchers consider compulsive buying an addiction similar to drug or alcohol misuse; others have linked it to depression or anxiety. Hollander³ and others have commented on its similarities with obsessive-compulsive disorder (OCD), and a recent study noted that compulsive buying is more common in patients with OCD than in matched controls.⁴ Still others—drawing on Kraepelin’s and Bleuler’s early work—consider compulsive buying an impulse control disorder, having features in common with pathological gambling and kleptomania.⁵

Prevalence. One survey estimates 2% to 8% of U.S. adults meet criteria for a compulsive shopping disorder, and community-based and clinical surveys suggest that 86% to 95% of them are women.⁵ The reported gender difference may be artifactual; women readily acknowledge that they enjoy shopping, whereas men are more likely to report that they “collect.”

Behavior patterns. No careful, longitudinal studies have examined compulsive buying disorder, but case reports suggest the condition is chronic, with a waxing and waning course and wide variance in symptom severity. In 20 consecutive patients with compulsive buying symptoms, one-half reported that irresistible urges prompted spending and three-quarters preferred to shop alone.⁶

Compulsive shoppers tend to shop frequently and spend inappropriately:

• at department and discount stores, specialty shops, and boutiques
  
• from mail order, television, and online merchants.
  

The behavior occurs year-round but might intensify around holidays or birthdays. Clothing, shoes, makeup, and jewelry are the most popular items women buy, though men with this disorder may focus on electronics, sporting equipment, or automobile accessories. When not actively buying, patients remain preoccupied with shopping, perusing mail order catalogs or newspaper ads and fantasizing about their next purchases.

While shopping, compulsive shoppers may report feeling intensely excited, happy, and powerful. These emotions are frequently followed by distress or guilt. They may return purchases or hide them in closets or attics, never to be used.

Low-income persons who shop compulsively may do so at consignment shops or garage sales. In one of our studies, the most severe compulsive buyers had the lowest incomes,⁶ suggesting that:

 

• lack of money does not prevent compulsive shopping disorder from developing
  
• severe compulsive shoppers lack the ability to delay their shopping.
  

Psychiatric comorbidity

Compulsive buyers differ from matched controls when dimensional scales are used to measure psychopathology. One study found that compulsive buyers had elevated scores on the Beck Depression Inventory, the Spielberger Trait Anxiety Scale, and the Maudsley Obsessive Compulsive Inventory.²

Compulsive buyers and their first-degree relatives often have comorbid psychiatric disorders, particularly mood, anxiety, substance use, and eating disorders.⁵ Axis II disorders are also common; no particular type predominates, but the obsessive-compulsive, borderline, and avoidant personality types are seen most frequently.

McElroy et al⁷ defined compulsive buying disorder as:

• uncontrollable
  
• markedly distressing, time-consuming, and/or resulting in family, social, vocational, and/or financial difficulties
  
• not occurring only in the context of hypomanic or manic symptoms.
  

In 20 consecutive patients meeting these criteria, lifetime diagnoses included major mood disorders in 19 (95%), anxiety disorders in 16 (80%), impulse control disorders in 8 (40%), and eating disorders in 7 (35%). These patients’ first-degree relatives also showed a high prevalence of major depression, substance abuse or alcoholism, and anxiety disorder.⁷

In a larger controlled study, our group⁸ compared 33 individuals who met the McElroy et al criteria for compulsive buying disorder and 22 control patients. The 137 first-degree relatives of the compulsive shoppers were significantly more likely than the controls’ relatives to have histories of depression, alcoholism, substance use, or multiple psychiatric diagnoses (as measured by the Family History Research Diagnostic Criteria).

Identifying a patient’s psychiatric comorbidities can help you develop:

• a biopsychosocial counseling plan—such as for a patient with borderline personality disorder who shops to relieve tension from relationship stress
  
• pharmacologic treatment strategies—such as prescribing a selective serotonin reuptake inhibitor (SSRI) for patients with comorbid major depression.
  

Manic versus compulsive behavior

Manic and hypomanic symptoms may be associated with impulsive and reckless spending. Thus, when evaluating excessive spending, always carefully evaluate patients for bipolar disorder.

Bipolar mania and excessive spending related to a compulsive buying disorder are relatively easy to differentiate:

• The manic patient’s unrestrained spending sprees correspond to manic episodes and are accompanied by euphoric mood, grandiosity, unrealistic plans, and often a giddy, overly bright affect.
  
• The compulsive shopper’s spending occurs year-round in a pattern suggesting ongoing preoccupation.
  

The compulsive buyer may feel happy (or powerful) while shopping, but these transitory emotions are usually followed by letdown or guilt. The compulsive shopper is distressed by his or her activity and will often hide the evidence.

Not so for the manic, who may boast of his or her spending, display the evidence, and try to convince family and friends that the purchase is necessary or fits into some grandiose scheme. “Who doesn’t need two BMWs?” a manic patient said to one of the authors [DWB].

Screening and diagnosis

As with any psychiatric disorder, gathering an accurate history through a careful interview is important. This can be challenging with compulsive shopping disorder, however, because the patient may minimize symptoms out of embarrassment or denial. Your goal is to identify the shopping problem through nonjudgmental inquiries.

Diagnostic instruments. Researchers use assessment tools such as Faber and O’Guinn’s 7-item Compulsive Buying Scale⁹ to help diagnose this disorder. Our group developed a shopping version of the Yale-Brown Obsessive Compulsive Scale (YBOCS-SV) to help rate severity and change during clinical trials.¹⁰

Formal instruments may help in the clinical setting, but you can often elicit compulsive buying symptoms with a few screening questions (Table 2). If screening indicates a positive response, move to more detailed questions about:

• frequency of excessive shopping
  
• time spent shopping
  
• factors that trigger or worsen the shopping behavior
  
• amount of money spent.
  

Collateral information from family and friends can supplement and clarify the patient’s self-report.

Table 2

Is your patient a compulsive shopper? Ask these screening questions

Do you feel preoccupied with shopping and spending?
Do you ever feel that your shopping behavior is excessive, inappropriate, or uncontrolled?
Have your shopping desires, urges, fantasies, or behaviors ever: been overly time-consuming caused you to feel upset or guilty led to serious problems, such as financial difficulties, legal problems, or relationship loss?
Source: Black DW. Assessment of compulsive buying. In: Benson AL, ed. I shop, therefore I am: Compulsive buying and the search for self. Northvale, NJ: Jason Aronson; 2000:191-216.

Medical history. Examine the patient’s history of physical illness, trauma, medications, or surgeries, as these may provide an organic explanation for the symptoms. Recent-onset compulsive shopping could be associated with a neurologic disorder or brain tumor, for example.

 

Stopping uncontrolled shopping

Compulsive shopping has no standard treatment, but evidence shows benefit from some SSRIs and psychotherapies.

Fluvoxamine. An early case series suggested antidepressants could curb compulsive buying,⁵ but later research has yielded mixed results.

Ms. A entered an experimental drug trial. She was randomly assigned to receive fluvoxamine and—despite difficulties with oversedation—tolerated a sustained dosage of 100 mg/d. After the 9-week trial, Ms. A said she thought less frequently about shopping, felt less compulsion to shop, and was spending less money and time shopping.

This open-label trial we conducted indicated that fluvoxamine, up to 300 mg/d, could be an effective treatment for compulsive buying.¹¹ Two subsequent randomized controlled trials, however, found fluvoxamine did no better than placebo when treating compulsive shoppers.^12,13

Citalopram. In an open-label trial,¹⁴ 23 women and 1 man who met diagnostic criteria for compulsive shopping disorder (YBOCS-SV scores ≥17) received citalopram for 7 weeks. Dosages started at 20 mg/d and were increased as tolerated to 60 mg/d. Fifteen patients (63%) met response criteria—“much improved” or “very much improved” as measured by the Clinical Global Impressions-Improvement scale and a ≥50% decrease in YBOCS-SV score. Three patients (13%) discontinued treatment because of adverse effects (headache, rash, insomnia).

The 15 responders were then enrolled in a 9-week double-blind, placebo-controlled trial. Compulsive shopping symptoms recurred in 5 of 8 patients (63%) assigned to placebo, compared with none of the 7 who continued taking citalopram.

By comparison, escitalopram, 10 to 20 mg/d, showed little effect for compulsive shopping symptoms in an identically designed discontinuation trial by the same investigators. During the 7-week, open-label trial, 19 of 26 patients met response criteria. In the 9-week double-blind, controlled phase, however, 63% of initial responders relapsed while taking escitalopram, compared with 67% of those randomized to placebo.¹⁵

A naturalistic follow-up study of 24 patients treated with citalopram, 20 to 60 mg/d, noted that patients who responded at 3 months were more likely to be symptom-free after 1 year than those who did not respond to acute treatment.¹⁶ Responders’ mean 2-week compulsive spending declined from $773 before treatment to $351 at 12 months, and their mean total debt declined from $17,833 to $16,752.

Because remission was not significantly associated with taking citalopram, however, the authors concluded that the mechanisms responsible for maintaining remission were unclear.

Psychotherapy. Cognitive-behavioral therapy (CBT) may help, but few therapists are familiar with this disorder. CBT challenges the patient’s cognitive distortions and faulty schemas about shopping, such as:

• “Having the latest fashions will make me more popular.”
  
• “Having 5 pair of new shoes will make me a happier and better person.”
  

CBT will then focus on teaching patients how to change these pathologic schemas. Preliminary evidence suggests that group CBT for compulsive shoppers can be effective.

Our recommendations. Medication—such as an antidepressant for major depression or a mood stabilizer for bipolar disorder—may improve compulsive shopping in patients with a comorbid psychiatric disorder. For other compulsive shoppers, however, medication trials provide little guidance for treatment.

We inform patients such as Ms. A that they cannot rely on medication to control their behavior. Instead, we recommend a four-step approach to break the compulsive shopping habit (Table 3).

Financial counseling, provided free of charge by many banks, benefits some patients. Self-help books describe strategies to overcome compulsive spending (Related resources). Debtors Anonymous, a 12-step program patterned after Alcoholics Anonymous, also can help by offering acceptance, belonging, forgiveness, and understanding.

In the most severe cases we recommend appointing a financial conservator to control the patient’s finances. We rarely advise this strategy but have encountered cases in which there seemed to be no other option. Having a conservator controls the patient’s spending but does not reverse the preoccupation with shopping.

Table 3

Patient education: 4 steps to control compulsive spending

Admit you are a compulsive shopper. Cut up the credit cards, and get rid of the checkbook—sources of easy credit fuel the problem. Shop only with a friend or relative; embarrassment will curb the tendency to overspend. Find meaningful ways to spend your time, other than shopping.

Related resources

For clinicians

• Black DW. Assessment of compulsive buying. In: Benson AL (ed). I shop, therefore I am: Compulsive buying and the search for self. Northvale, NJ: Jason Aronson; 2000:191-216.
  

For patients

• Arenson G. Born to spend: how to overcome compulsive spending. Blue Ridge Summit, PA: Tab Books, 1991.
  
• Benson AL. Stopping Overshopping. A site for shopaholics and the people who love them. www.stoppingovershopping.com.
  
• Mellan O. Money harmony: resolving money conflicts in your life and relationships. New York: Walker, 2005.
  

 

Drug brand names

• Citalopram • Celexa
  
• Escitalopram • Lexapro
  
• Fluvoxamine • Luvox
  

Disclosures

Dr. Kuzma reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Dr. Black receives grant/research support or is a consultant or speaker for Forest Laboratories and Shire Pharmaceuticals

Ms. A has been compulsively shopping and spending since age 19 when she first obtained credit cards. After years of intense urges to shop and remorse over the financial consequences, she seeks psychiatric help. Now age 37 and divorced, she has controlled her spending only for two 1- to 2-year periods that coincided with bankruptcy proceedings.

With easy access to credit, many persons such as Ms. A develop what is variously called compulsive buying, compulsive shopping, addictive shopping, or shopaholism. Although “medicalizing” excessive shopping may seem to obscure its broader cultural and social causes,¹ increasing evidence points to a discrete shopping disorder.

Our group has contributed to compulsive buying research and continues to evaluate potential treatments. We offer evidence and practical advice to help you:

• identify compulsive shopping disorder using the patient’s history and three screening questions
  
• differentiate compulsive shopping from manic or hypomanic shopping sprees
  
• educate patients about four steps to control compulsive shopping.
  

Table 1

Compulsive shopping disorder’s clinical signs

Onset in late adolescence to early adulthood
Female-to-male ratio may be 9:1
Behaviors include shopping frequently, spending inappropriately, and fantasizing about future purchases
Psychiatric comorbidity—mood disorders, substance abuse, eating disorders—is common among patients and first-degree relatives
Chronic symptoms wax and wane, with widely varying severity
Irresistible urges prompt spending by some patients
Shopping is intensely exciting, with transitory feelings of happiness and power
Feelings of distress and guilt develop after shopping; patients often hide purchases
Patients may be in denial or feel embarrassed to disclose symptoms

An Evolving Picture

Ms. A says shopping is her primary social activity and entertainment. Though she works full time, she shops three or more times a week, cruising expensive department stores and discount outlets on evenings and weekends. She buys clothing, shoes, makeup, jewelry, antiques, household electronics, and other items.

She says her shopping is spontaneous and impulsive. Shopping gives her an emotional “rush” that is frequently followed by periods of guilt, and she often returns or gives away purchased items. She is disappointed at her inability to control her shopping behavior and ashamed of the financial crises she has caused.

Compulsive buying is characterized by persistent or poorly controlled preoccupations, urges, or behaviors regarding shopping or spending, leading to adverse consequences.² Onset in late adolescence to early adulthood is the usual pattern, and the disorder is thought to be chronic or recurrent. It is not listed in DSM-IV-TR but is considered an example of an impulse control disorder not otherwise specified. For this paper, we use the terms compulsive shopping and compulsive buying interchangeably.

The disorder’s tentative classification reflects debate about its conceptualization. Some clinicians and researchers consider compulsive buying an addiction similar to drug or alcohol misuse; others have linked it to depression or anxiety. Hollander³ and others have commented on its similarities with obsessive-compulsive disorder (OCD), and a recent study noted that compulsive buying is more common in patients with OCD than in matched controls.⁴ Still others—drawing on Kraepelin’s and Bleuler’s early work—consider compulsive buying an impulse control disorder, having features in common with pathological gambling and kleptomania.⁵

Prevalence. One survey estimates 2% to 8% of U.S. adults meet criteria for a compulsive shopping disorder, and community-based and clinical surveys suggest that 86% to 95% of them are women.⁵ The reported gender difference may be artifactual; women readily acknowledge that they enjoy shopping, whereas men are more likely to report that they “collect.”

Behavior patterns. No careful, longitudinal studies have examined compulsive buying disorder, but case reports suggest the condition is chronic, with a waxing and waning course and wide variance in symptom severity. In 20 consecutive patients with compulsive buying symptoms, one-half reported that irresistible urges prompted spending and three-quarters preferred to shop alone.⁶

Compulsive shoppers tend to shop frequently and spend inappropriately:

• at department and discount stores, specialty shops, and boutiques
  
• from mail order, television, and online merchants.
  

The behavior occurs year-round but might intensify around holidays or birthdays. Clothing, shoes, makeup, and jewelry are the most popular items women buy, though men with this disorder may focus on electronics, sporting equipment, or automobile accessories. When not actively buying, patients remain preoccupied with shopping, perusing mail order catalogs or newspaper ads and fantasizing about their next purchases.

While shopping, compulsive shoppers may report feeling intensely excited, happy, and powerful. These emotions are frequently followed by distress or guilt. They may return purchases or hide them in closets or attics, never to be used.

Low-income persons who shop compulsively may do so at consignment shops or garage sales. In one of our studies, the most severe compulsive buyers had the lowest incomes,⁶ suggesting that:

 

• lack of money does not prevent compulsive shopping disorder from developing
  
• severe compulsive shoppers lack the ability to delay their shopping.
  

Psychiatric comorbidity

Compulsive buyers differ from matched controls when dimensional scales are used to measure psychopathology. One study found that compulsive buyers had elevated scores on the Beck Depression Inventory, the Spielberger Trait Anxiety Scale, and the Maudsley Obsessive Compulsive Inventory.²

Compulsive buyers and their first-degree relatives often have comorbid psychiatric disorders, particularly mood, anxiety, substance use, and eating disorders.⁵ Axis II disorders are also common; no particular type predominates, but the obsessive-compulsive, borderline, and avoidant personality types are seen most frequently.

McElroy et al⁷ defined compulsive buying disorder as:

• uncontrollable
  
• markedly distressing, time-consuming, and/or resulting in family, social, vocational, and/or financial difficulties
  
• not occurring only in the context of hypomanic or manic symptoms.
  

In 20 consecutive patients meeting these criteria, lifetime diagnoses included major mood disorders in 19 (95%), anxiety disorders in 16 (80%), impulse control disorders in 8 (40%), and eating disorders in 7 (35%). These patients’ first-degree relatives also showed a high prevalence of major depression, substance abuse or alcoholism, and anxiety disorder.⁷

In a larger controlled study, our group⁸ compared 33 individuals who met the McElroy et al criteria for compulsive buying disorder and 22 control patients. The 137 first-degree relatives of the compulsive shoppers were significantly more likely than the controls’ relatives to have histories of depression, alcoholism, substance use, or multiple psychiatric diagnoses (as measured by the Family History Research Diagnostic Criteria).

Identifying a patient’s psychiatric comorbidities can help you develop:

• a biopsychosocial counseling plan—such as for a patient with borderline personality disorder who shops to relieve tension from relationship stress
  
• pharmacologic treatment strategies—such as prescribing a selective serotonin reuptake inhibitor (SSRI) for patients with comorbid major depression.
  

Manic versus compulsive behavior

Manic and hypomanic symptoms may be associated with impulsive and reckless spending. Thus, when evaluating excessive spending, always carefully evaluate patients for bipolar disorder.

Bipolar mania and excessive spending related to a compulsive buying disorder are relatively easy to differentiate:

• The manic patient’s unrestrained spending sprees correspond to manic episodes and are accompanied by euphoric mood, grandiosity, unrealistic plans, and often a giddy, overly bright affect.
  
• The compulsive shopper’s spending occurs year-round in a pattern suggesting ongoing preoccupation.
  

The compulsive buyer may feel happy (or powerful) while shopping, but these transitory emotions are usually followed by letdown or guilt. The compulsive shopper is distressed by his or her activity and will often hide the evidence.

Not so for the manic, who may boast of his or her spending, display the evidence, and try to convince family and friends that the purchase is necessary or fits into some grandiose scheme. “Who doesn’t need two BMWs?” a manic patient said to one of the authors [DWB].

Screening and diagnosis

As with any psychiatric disorder, gathering an accurate history through a careful interview is important. This can be challenging with compulsive shopping disorder, however, because the patient may minimize symptoms out of embarrassment or denial. Your goal is to identify the shopping problem through nonjudgmental inquiries.

Diagnostic instruments. Researchers use assessment tools such as Faber and O’Guinn’s 7-item Compulsive Buying Scale⁹ to help diagnose this disorder. Our group developed a shopping version of the Yale-Brown Obsessive Compulsive Scale (YBOCS-SV) to help rate severity and change during clinical trials.¹⁰

Formal instruments may help in the clinical setting, but you can often elicit compulsive buying symptoms with a few screening questions (Table 2). If screening indicates a positive response, move to more detailed questions about:

• frequency of excessive shopping
  
• time spent shopping
  
• factors that trigger or worsen the shopping behavior
  
• amount of money spent.
  

Collateral information from family and friends can supplement and clarify the patient’s self-report.

Table 2

Is your patient a compulsive shopper? Ask these screening questions

Do you feel preoccupied with shopping and spending?
Do you ever feel that your shopping behavior is excessive, inappropriate, or uncontrolled?
Have your shopping desires, urges, fantasies, or behaviors ever: been overly time-consuming caused you to feel upset or guilty led to serious problems, such as financial difficulties, legal problems, or relationship loss?
Source: Black DW. Assessment of compulsive buying. In: Benson AL, ed. I shop, therefore I am: Compulsive buying and the search for self. Northvale, NJ: Jason Aronson; 2000:191-216.

Medical history. Examine the patient’s history of physical illness, trauma, medications, or surgeries, as these may provide an organic explanation for the symptoms. Recent-onset compulsive shopping could be associated with a neurologic disorder or brain tumor, for example.

 

Stopping uncontrolled shopping

Compulsive shopping has no standard treatment, but evidence shows benefit from some SSRIs and psychotherapies.

Fluvoxamine. An early case series suggested antidepressants could curb compulsive buying,⁵ but later research has yielded mixed results.

Ms. A entered an experimental drug trial. She was randomly assigned to receive fluvoxamine and—despite difficulties with oversedation—tolerated a sustained dosage of 100 mg/d. After the 9-week trial, Ms. A said she thought less frequently about shopping, felt less compulsion to shop, and was spending less money and time shopping.

This open-label trial we conducted indicated that fluvoxamine, up to 300 mg/d, could be an effective treatment for compulsive buying.¹¹ Two subsequent randomized controlled trials, however, found fluvoxamine did no better than placebo when treating compulsive shoppers.^12,13

Citalopram. In an open-label trial,¹⁴ 23 women and 1 man who met diagnostic criteria for compulsive shopping disorder (YBOCS-SV scores ≥17) received citalopram for 7 weeks. Dosages started at 20 mg/d and were increased as tolerated to 60 mg/d. Fifteen patients (63%) met response criteria—“much improved” or “very much improved” as measured by the Clinical Global Impressions-Improvement scale and a ≥50% decrease in YBOCS-SV score. Three patients (13%) discontinued treatment because of adverse effects (headache, rash, insomnia).

The 15 responders were then enrolled in a 9-week double-blind, placebo-controlled trial. Compulsive shopping symptoms recurred in 5 of 8 patients (63%) assigned to placebo, compared with none of the 7 who continued taking citalopram.

By comparison, escitalopram, 10 to 20 mg/d, showed little effect for compulsive shopping symptoms in an identically designed discontinuation trial by the same investigators. During the 7-week, open-label trial, 19 of 26 patients met response criteria. In the 9-week double-blind, controlled phase, however, 63% of initial responders relapsed while taking escitalopram, compared with 67% of those randomized to placebo.¹⁵

A naturalistic follow-up study of 24 patients treated with citalopram, 20 to 60 mg/d, noted that patients who responded at 3 months were more likely to be symptom-free after 1 year than those who did not respond to acute treatment.¹⁶ Responders’ mean 2-week compulsive spending declined from $773 before treatment to $351 at 12 months, and their mean total debt declined from $17,833 to $16,752.

Because remission was not significantly associated with taking citalopram, however, the authors concluded that the mechanisms responsible for maintaining remission were unclear.

Psychotherapy. Cognitive-behavioral therapy (CBT) may help, but few therapists are familiar with this disorder. CBT challenges the patient’s cognitive distortions and faulty schemas about shopping, such as:

• “Having the latest fashions will make me more popular.”
  
• “Having 5 pair of new shoes will make me a happier and better person.”
  

CBT will then focus on teaching patients how to change these pathologic schemas. Preliminary evidence suggests that group CBT for compulsive shoppers can be effective.

Our recommendations. Medication—such as an antidepressant for major depression or a mood stabilizer for bipolar disorder—may improve compulsive shopping in patients with a comorbid psychiatric disorder. For other compulsive shoppers, however, medication trials provide little guidance for treatment.

We inform patients such as Ms. A that they cannot rely on medication to control their behavior. Instead, we recommend a four-step approach to break the compulsive shopping habit (Table 3).

Financial counseling, provided free of charge by many banks, benefits some patients. Self-help books describe strategies to overcome compulsive spending (Related resources). Debtors Anonymous, a 12-step program patterned after Alcoholics Anonymous, also can help by offering acceptance, belonging, forgiveness, and understanding.

In the most severe cases we recommend appointing a financial conservator to control the patient’s finances. We rarely advise this strategy but have encountered cases in which there seemed to be no other option. Having a conservator controls the patient’s spending but does not reverse the preoccupation with shopping.

Table 3

Patient education: 4 steps to control compulsive spending

Admit you are a compulsive shopper. Cut up the credit cards, and get rid of the checkbook—sources of easy credit fuel the problem. Shop only with a friend or relative; embarrassment will curb the tendency to overspend. Find meaningful ways to spend your time, other than shopping.

Related resources

For clinicians

• Black DW. Assessment of compulsive buying. In: Benson AL (ed). I shop, therefore I am: Compulsive buying and the search for self. Northvale, NJ: Jason Aronson; 2000:191-216.
  

For patients

• Arenson G. Born to spend: how to overcome compulsive spending. Blue Ridge Summit, PA: Tab Books, 1991.
  
• Benson AL. Stopping Overshopping. A site for shopaholics and the people who love them. www.stoppingovershopping.com.
  
• Mellan O. Money harmony: resolving money conflicts in your life and relationships. New York: Walker, 2005.
  

 

Drug brand names

• Citalopram • Celexa
  
• Escitalopram • Lexapro
  
• Fluvoxamine • Luvox
  

Disclosures

Dr. Kuzma reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Dr. Black receives grant/research support or is a consultant or speaker for Forest Laboratories and Shire Pharmaceuticals

Ms. A has been compulsively shopping and spending since age 19 when she first obtained credit cards. After years of intense urges to shop and remorse over the financial consequences, she seeks psychiatric help. Now age 37 and divorced, she has controlled her spending only for two 1- to 2-year periods that coincided with bankruptcy proceedings.

With easy access to credit, many persons such as Ms. A develop what is variously called compulsive buying, compulsive shopping, addictive shopping, or shopaholism. Although “medicalizing” excessive shopping may seem to obscure its broader cultural and social causes,¹ increasing evidence points to a discrete shopping disorder.

Our group has contributed to compulsive buying research and continues to evaluate potential treatments. We offer evidence and practical advice to help you:

• identify compulsive shopping disorder using the patient’s history and three screening questions
  
• differentiate compulsive shopping from manic or hypomanic shopping sprees
  
• educate patients about four steps to control compulsive shopping.
  

Table 1

Compulsive shopping disorder’s clinical signs

Onset in late adolescence to early adulthood
Female-to-male ratio may be 9:1
Behaviors include shopping frequently, spending inappropriately, and fantasizing about future purchases
Psychiatric comorbidity—mood disorders, substance abuse, eating disorders—is common among patients and first-degree relatives
Chronic symptoms wax and wane, with widely varying severity
Irresistible urges prompt spending by some patients
Shopping is intensely exciting, with transitory feelings of happiness and power
Feelings of distress and guilt develop after shopping; patients often hide purchases
Patients may be in denial or feel embarrassed to disclose symptoms

An Evolving Picture

Ms. A says shopping is her primary social activity and entertainment. Though she works full time, she shops three or more times a week, cruising expensive department stores and discount outlets on evenings and weekends. She buys clothing, shoes, makeup, jewelry, antiques, household electronics, and other items.

She says her shopping is spontaneous and impulsive. Shopping gives her an emotional “rush” that is frequently followed by periods of guilt, and she often returns or gives away purchased items. She is disappointed at her inability to control her shopping behavior and ashamed of the financial crises she has caused.

Compulsive buying is characterized by persistent or poorly controlled preoccupations, urges, or behaviors regarding shopping or spending, leading to adverse consequences.² Onset in late adolescence to early adulthood is the usual pattern, and the disorder is thought to be chronic or recurrent. It is not listed in DSM-IV-TR but is considered an example of an impulse control disorder not otherwise specified. For this paper, we use the terms compulsive shopping and compulsive buying interchangeably.

The disorder’s tentative classification reflects debate about its conceptualization. Some clinicians and researchers consider compulsive buying an addiction similar to drug or alcohol misuse; others have linked it to depression or anxiety. Hollander³ and others have commented on its similarities with obsessive-compulsive disorder (OCD), and a recent study noted that compulsive buying is more common in patients with OCD than in matched controls.⁴ Still others—drawing on Kraepelin’s and Bleuler’s early work—consider compulsive buying an impulse control disorder, having features in common with pathological gambling and kleptomania.⁵

Prevalence. One survey estimates 2% to 8% of U.S. adults meet criteria for a compulsive shopping disorder, and community-based and clinical surveys suggest that 86% to 95% of them are women.⁵ The reported gender difference may be artifactual; women readily acknowledge that they enjoy shopping, whereas men are more likely to report that they “collect.”

Behavior patterns. No careful, longitudinal studies have examined compulsive buying disorder, but case reports suggest the condition is chronic, with a waxing and waning course and wide variance in symptom severity. In 20 consecutive patients with compulsive buying symptoms, one-half reported that irresistible urges prompted spending and three-quarters preferred to shop alone.⁶

Compulsive shoppers tend to shop frequently and spend inappropriately:

• at department and discount stores, specialty shops, and boutiques
  
• from mail order, television, and online merchants.
  

The behavior occurs year-round but might intensify around holidays or birthdays. Clothing, shoes, makeup, and jewelry are the most popular items women buy, though men with this disorder may focus on electronics, sporting equipment, or automobile accessories. When not actively buying, patients remain preoccupied with shopping, perusing mail order catalogs or newspaper ads and fantasizing about their next purchases.

While shopping, compulsive shoppers may report feeling intensely excited, happy, and powerful. These emotions are frequently followed by distress or guilt. They may return purchases or hide them in closets or attics, never to be used.

Low-income persons who shop compulsively may do so at consignment shops or garage sales. In one of our studies, the most severe compulsive buyers had the lowest incomes,⁶ suggesting that:

 

• lack of money does not prevent compulsive shopping disorder from developing
  
• severe compulsive shoppers lack the ability to delay their shopping.
  

Psychiatric comorbidity

Compulsive buyers differ from matched controls when dimensional scales are used to measure psychopathology. One study found that compulsive buyers had elevated scores on the Beck Depression Inventory, the Spielberger Trait Anxiety Scale, and the Maudsley Obsessive Compulsive Inventory.²

Compulsive buyers and their first-degree relatives often have comorbid psychiatric disorders, particularly mood, anxiety, substance use, and eating disorders.⁵ Axis II disorders are also common; no particular type predominates, but the obsessive-compulsive, borderline, and avoidant personality types are seen most frequently.

McElroy et al⁷ defined compulsive buying disorder as:

• uncontrollable
  
• markedly distressing, time-consuming, and/or resulting in family, social, vocational, and/or financial difficulties
  
• not occurring only in the context of hypomanic or manic symptoms.
  

In 20 consecutive patients meeting these criteria, lifetime diagnoses included major mood disorders in 19 (95%), anxiety disorders in 16 (80%), impulse control disorders in 8 (40%), and eating disorders in 7 (35%). These patients’ first-degree relatives also showed a high prevalence of major depression, substance abuse or alcoholism, and anxiety disorder.⁷

In a larger controlled study, our group⁸ compared 33 individuals who met the McElroy et al criteria for compulsive buying disorder and 22 control patients. The 137 first-degree relatives of the compulsive shoppers were significantly more likely than the controls’ relatives to have histories of depression, alcoholism, substance use, or multiple psychiatric diagnoses (as measured by the Family History Research Diagnostic Criteria).

Identifying a patient’s psychiatric comorbidities can help you develop:

• a biopsychosocial counseling plan—such as for a patient with borderline personality disorder who shops to relieve tension from relationship stress
  
• pharmacologic treatment strategies—such as prescribing a selective serotonin reuptake inhibitor (SSRI) for patients with comorbid major depression.
  

Manic versus compulsive behavior

Manic and hypomanic symptoms may be associated with impulsive and reckless spending. Thus, when evaluating excessive spending, always carefully evaluate patients for bipolar disorder.

Bipolar mania and excessive spending related to a compulsive buying disorder are relatively easy to differentiate:

• The manic patient’s unrestrained spending sprees correspond to manic episodes and are accompanied by euphoric mood, grandiosity, unrealistic plans, and often a giddy, overly bright affect.
  
• The compulsive shopper’s spending occurs year-round in a pattern suggesting ongoing preoccupation.
  

The compulsive buyer may feel happy (or powerful) while shopping, but these transitory emotions are usually followed by letdown or guilt. The compulsive shopper is distressed by his or her activity and will often hide the evidence.

Not so for the manic, who may boast of his or her spending, display the evidence, and try to convince family and friends that the purchase is necessary or fits into some grandiose scheme. “Who doesn’t need two BMWs?” a manic patient said to one of the authors [DWB].

Screening and diagnosis

As with any psychiatric disorder, gathering an accurate history through a careful interview is important. This can be challenging with compulsive shopping disorder, however, because the patient may minimize symptoms out of embarrassment or denial. Your goal is to identify the shopping problem through nonjudgmental inquiries.

Diagnostic instruments. Researchers use assessment tools such as Faber and O’Guinn’s 7-item Compulsive Buying Scale⁹ to help diagnose this disorder. Our group developed a shopping version of the Yale-Brown Obsessive Compulsive Scale (YBOCS-SV) to help rate severity and change during clinical trials.¹⁰

Formal instruments may help in the clinical setting, but you can often elicit compulsive buying symptoms with a few screening questions (Table 2). If screening indicates a positive response, move to more detailed questions about:

• frequency of excessive shopping
  
• time spent shopping
  
• factors that trigger or worsen the shopping behavior
  
• amount of money spent.
  

Collateral information from family and friends can supplement and clarify the patient’s self-report.

Table 2

Is your patient a compulsive shopper? Ask these screening questions

Do you feel preoccupied with shopping and spending?
Do you ever feel that your shopping behavior is excessive, inappropriate, or uncontrolled?
Have your shopping desires, urges, fantasies, or behaviors ever: been overly time-consuming caused you to feel upset or guilty led to serious problems, such as financial difficulties, legal problems, or relationship loss?
Source: Black DW. Assessment of compulsive buying. In: Benson AL, ed. I shop, therefore I am: Compulsive buying and the search for self. Northvale, NJ: Jason Aronson; 2000:191-216.

Medical history. Examine the patient’s history of physical illness, trauma, medications, or surgeries, as these may provide an organic explanation for the symptoms. Recent-onset compulsive shopping could be associated with a neurologic disorder or brain tumor, for example.

 

Stopping uncontrolled shopping

Compulsive shopping has no standard treatment, but evidence shows benefit from some SSRIs and psychotherapies.

Fluvoxamine. An early case series suggested antidepressants could curb compulsive buying,⁵ but later research has yielded mixed results.

Ms. A entered an experimental drug trial. She was randomly assigned to receive fluvoxamine and—despite difficulties with oversedation—tolerated a sustained dosage of 100 mg/d. After the 9-week trial, Ms. A said she thought less frequently about shopping, felt less compulsion to shop, and was spending less money and time shopping.

This open-label trial we conducted indicated that fluvoxamine, up to 300 mg/d, could be an effective treatment for compulsive buying.¹¹ Two subsequent randomized controlled trials, however, found fluvoxamine did no better than placebo when treating compulsive shoppers.^12,13

Citalopram. In an open-label trial,¹⁴ 23 women and 1 man who met diagnostic criteria for compulsive shopping disorder (YBOCS-SV scores ≥17) received citalopram for 7 weeks. Dosages started at 20 mg/d and were increased as tolerated to 60 mg/d. Fifteen patients (63%) met response criteria—“much improved” or “very much improved” as measured by the Clinical Global Impressions-Improvement scale and a ≥50% decrease in YBOCS-SV score. Three patients (13%) discontinued treatment because of adverse effects (headache, rash, insomnia).

The 15 responders were then enrolled in a 9-week double-blind, placebo-controlled trial. Compulsive shopping symptoms recurred in 5 of 8 patients (63%) assigned to placebo, compared with none of the 7 who continued taking citalopram.

By comparison, escitalopram, 10 to 20 mg/d, showed little effect for compulsive shopping symptoms in an identically designed discontinuation trial by the same investigators. During the 7-week, open-label trial, 19 of 26 patients met response criteria. In the 9-week double-blind, controlled phase, however, 63% of initial responders relapsed while taking escitalopram, compared with 67% of those randomized to placebo.¹⁵

A naturalistic follow-up study of 24 patients treated with citalopram, 20 to 60 mg/d, noted that patients who responded at 3 months were more likely to be symptom-free after 1 year than those who did not respond to acute treatment.¹⁶ Responders’ mean 2-week compulsive spending declined from $773 before treatment to $351 at 12 months, and their mean total debt declined from $17,833 to $16,752.

Because remission was not significantly associated with taking citalopram, however, the authors concluded that the mechanisms responsible for maintaining remission were unclear.

Psychotherapy. Cognitive-behavioral therapy (CBT) may help, but few therapists are familiar with this disorder. CBT challenges the patient’s cognitive distortions and faulty schemas about shopping, such as:

• “Having the latest fashions will make me more popular.”
  
• “Having 5 pair of new shoes will make me a happier and better person.”
  

CBT will then focus on teaching patients how to change these pathologic schemas. Preliminary evidence suggests that group CBT for compulsive shoppers can be effective.

Our recommendations. Medication—such as an antidepressant for major depression or a mood stabilizer for bipolar disorder—may improve compulsive shopping in patients with a comorbid psychiatric disorder. For other compulsive shoppers, however, medication trials provide little guidance for treatment.

We inform patients such as Ms. A that they cannot rely on medication to control their behavior. Instead, we recommend a four-step approach to break the compulsive shopping habit (Table 3).

Financial counseling, provided free of charge by many banks, benefits some patients. Self-help books describe strategies to overcome compulsive spending (Related resources). Debtors Anonymous, a 12-step program patterned after Alcoholics Anonymous, also can help by offering acceptance, belonging, forgiveness, and understanding.

In the most severe cases we recommend appointing a financial conservator to control the patient’s finances. We rarely advise this strategy but have encountered cases in which there seemed to be no other option. Having a conservator controls the patient’s spending but does not reverse the preoccupation with shopping.

Table 3

Patient education: 4 steps to control compulsive spending

Admit you are a compulsive shopper. Cut up the credit cards, and get rid of the checkbook—sources of easy credit fuel the problem. Shop only with a friend or relative; embarrassment will curb the tendency to overspend. Find meaningful ways to spend your time, other than shopping.

Related resources

For clinicians

• Black DW. Assessment of compulsive buying. In: Benson AL (ed). I shop, therefore I am: Compulsive buying and the search for self. Northvale, NJ: Jason Aronson; 2000:191-216.
  

For patients

• Arenson G. Born to spend: how to overcome compulsive spending. Blue Ridge Summit, PA: Tab Books, 1991.
  
• Benson AL. Stopping Overshopping. A site for shopaholics and the people who love them. www.stoppingovershopping.com.
  
• Mellan O. Money harmony: resolving money conflicts in your life and relationships. New York: Walker, 2005.
  

 

Drug brand names

• Citalopram • Celexa
  
• Escitalopram • Lexapro
  
• Fluvoxamine • Luvox
  

Disclosures

Dr. Kuzma reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Dr. Black receives grant/research support or is a consultant or speaker for Forest Laboratories and Shire Pharmaceuticals