Abstract
Although not officially recognized as a mental disorder, compulsive buying is a serious and chronic problem that causes significant impairments in social, occupational, and interpersonal areas of functioning. In anticipation of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V), many researchers have argued for the acknowledgement of this condition as a mental disorder. In addition to reviewing the extant research on compulsive buying and the evidence supporting its validity as a mental illness, this paper explores the possible classifications of the disorder in the context of proposed revisions to the DSM-V. Although more research is needed to elucidate the nature of the disorder, it is concluded that CBD should be classified as an impulse control disorder, rather than an addiction or obsessive-compulsive disorder.
Compulsive buying disorder (CBD): Conceptualization and classification
The DSM task force is busy preparing for the publication of its 5th edition of the Diagnostic and Statistical Manual of Mental Disorders, which is set to be released sometime in May, 2013 (American Psychiatric Association, 2010). In anticipation of its release, there has been a surge in research evaluating the current organization and classification of mental disorders in the DSM-IV-TR and several recommendations have been made for the 5th edition. Perhaps the most notable, and indeed the most controversial, revision being considered for the DSM-V is the introduction of several new disorders. One of the disorders being considered for inclusion is Compulsive Buying Disorder (CBD) . Below is a review of the extant research on CBD, including its symptomology, epidemiology, comorbidity, and possible classifications if and when it is included into the DSM.
Compulsive Buying Disorder (CBD): Definition, clinical symptoms, epidemiology, and comorbidity
Although it is not included in the DSM-IV-TR (American Psychiatric Association, 2000), Compulsive Buying Disorder (CBD) has received considerable attention in the literature since the 1990's, when clinical case studies first started to appear (McElroy, Keck, Pope et al., 1994; Schlosser, Black, Repertinger, & Freet, 1994). Currently, people presenting symptoms consistent with CBD are diagnosed with "Impulse Control Disorder Not Otherwise Specified". However, the classification of the disorder has been a topic of much debate. Notwithstanding this disagreement over the nosology of CBD, there is a general consensus within the literature that it is a serious condition (Hartson & Horan, 2002) characterized by excessively or poorly controlled preoccupations, urges, or behaviours with regard to shopping or buying (Black, 2001), which can lead to negative consequences such as remorse, excessive debt, marital and family conflict and even suicide attempts (O'Guinn & Faber, 1989; McElroy et al., 1997; Koran, Faber, Aboujaoude, Large, & Serpe, 2006).
The diagnostic criteria for CBD proposed by McElroy et al. (1994) has received widespread acceptance among researchers and has been used in several studies as a threshold for the disorder (see Appendix A for McElroy et al. (1994) diagnostic criteria for CBD). The core elements of the criteria include: (1) Frequent preoccupation with shopping or intrusive, irresistible, 'senseless' buying impulses; (2) clearly buying more than is needed or can be afforded; (3) distress related to buying behaviour; and (4) significant interference with work or social functioning.
The estimated prevalence of CBD in the adult U.S. population is about 5.8% (Koran et al., 2006), although prevalence rates as low 1.8% (Faber & O'Guinn, 1989) and as high as 8% (Magee, 1991) have been reported in the literature. Caution must be exercised, however, when interpreting such prevalence rates because, other than McElroy et al. (1994) proposed criteria which was based on 20 reported cases, CBD currently lacks a definitive criteria.
The age of onset for CBD appears to be in the late teens to early 20's (Black, 2001). The preponderance of people identified as compulsive buyers are female, constituting, on average, 80-95% of clinical samples (Schlosser et al., 1994; McElroy et al., 1994). However, a recent study (Koran et al., 2006) using a large general population sample found that the prevalence rates of CBD between men and women were only marginally different. The disparity between gender rates of CBD in clinical and community samples may be explained by female's greater willingness than men to seek therapy for their compulsive shopping.
Comorbidity rates among people with CBD are exceedingly high (McElroy et al., 1994; Schlosser et al., 1994). Among the Axis I disorders commonly associated with CBD are mood, anxiety, substance use and eating disorders. In Schlosser et al. (1994) clinical sample of 46 people with CBD, 60% met the criteria for at least one personality disorder, most commonly obsessive compulsive (22%). Furthermore, first-degree relatives (FDRs) of individuals with CBD are more likely to have psychiatric disorders such as alcohol or substance abuse, major depression, and anxiety disorders than FDRs of people without CBD (McElroy et al., 1994; Black et al., 1998).
Four distinct phases of CBD have been identified (Black, 2007): 1) anticipation; 2) preparation; 3) shopping; and 4) spending. In the first phase, the person has thoughts or preoccupations with having a certain item or shopping in general. The second phase involves preparing for shopping which may include deciding at which store to shop, what clothes to wear, and even which credit card to use. The third phase involves the actual act of shopping. Many people with CBD have reported that they feel exhilarated when shopping and in some this may lead to sexual feelings (Schlosser et al., 1994). Finally, the last phase involves the purchasing of the item, after which the person may be overwhelmed with feelings of shame and embarrassment (Hartston & Koran, 2002). Clothes, shoes, jewellery, and makeup are among the most common items purchased by women, whereas men are more likely to purchase electronic, hardware, and automotive products (Black, 2001; Black, 2007).
In a study exploring the antecedents and consequences of compulsive buying, Miltenberger et al. (2003) found that negative emotions such as depression, anxiety, boredom, and self-critical thoughts were common antecedents to compulsive buying, whereas euphoria and relief of negative emotions were often consequences. Thus, in individuals with CBD, shopping appears to be a primary response to stress (O'Guinn & Faber, 1989) and used as a means of mood elevation (Clark & Calleja, 2008). The pleasurable feelings associated with shopping in people with CBD are positively reinforcing and the alleviation of anxiety and depressed mood is negatively reinforcing, both of which serve to perpetuate the behaviour.
Research has consistently found that people who buy compulsively display higher rates of the compulsive personality trait, have lower self-esteems, depressed moods, more compromised self-perceptions and perfectionistic expectations, more decision making difficulties, and are more prone to fantasy than people with more normal buying behaviour (O'Guinn & Faber, 1989; Kyrios, Frost, & Steketee, 2004). Rose (2007) reported a positive correlation between narcissism, materialism, and compulsive buying, and a negative association between impulse control and each of these variables in people with CBD.
Criticism of CBD
Although many researchers have argued for the inclusion of CBD into the DSM, some feel that it is not a bona fide mental illness (Shirley & Avis, 2004). Compulsive shopping, they argue, and other similar controversial disorders such as "internet" and "sex addictions" are moral, rather than medical, problems. They also criticize the medical and scientific community's eagerness to "medicalize" deviant behaviour, which they perceive as attempts to create more conditions to treat with pharmaceutical drugs. Similar criticisms have been made towards attention deficit hyperactivity disorder (ADHD) and social anxiety disorder, which some argue are just normal traits that have been ascribed medical labels and treated with drugs (Hollander, 2006). However, creating a new diagnosis is a complex process, and much of the attack directed at the validity of certain mental disorders has come from armchair critics.
Granted, the line between "excessive" and "compulsive" or "disordered" buying is arbitrary at best, but this is true of most, if not all, mental disorders in the DSM. Moreover, the clinical emphasis of CBD is not on the amount of the behaviour-many people in our culture of consumerism shop "excessively" or purchase items that they don't need-but rather the consequences of the behaviour. Asserting that conditions such as CBD, ADHD, and social phobia are "trivial" disorders, not worthy of diagnosis and treatment undermines the serious social, occupational, and interpersonal disruptions that these disorders often cause when untreated. Others have pointed out that including a disorder into the DSM, even if it is seemingly "trivial" or controversial, is very important for augmenting knowledge about that particular condition because it provides researchers with a specific set of criteria to use in their research (Hollander, 2006), which can then be used to refine and improve the disorder's criteria.
Compulsive Buying Disorder: Classification
Though it may not seem that important, the nosology of a mental disorder has profound implications. As mentioned previously, CBD is not currently recognized by the DSM-IV-TR as a mental disorder and, as such, the classification of CBD, upon inclusion into the DSM, has been a topic of much debate among researchers investigating the disorder. Three possible classifications for CBD have been proposed.
Option 1: CBD as an Addictive Disorder
The rationale behind classifying some impulse control disorders, such as compulsive shopping and pathological gambling (PB), as behavioural addictions is that they share many important features-clinical symptoms, comorbidity, family history, brain circuitry, and treatment responses to SSRI's-with substance addictions (Bernardo et al., 2008; Hollander, 2009).
Currently, the nomenclature of the DSM-IV-TR lacks the term "addiction". However, one of the proposed revisions being considered for the DSM-V is the removal of the "substance use disorder" (SUD) section and the adoption of an "addiction and related disorders" category. Many researchers have advocated for the complete abolishment of the terms "substance" and "dependence", as research has shown that these terms are misleading and problematic. For example, tolerance and withdrawal are generally considered to be the trademark symptoms of substance dependence, but people can become tolerant to and experience withdrawal symptoms from a drug without necessarily being addicted to it.
Thus, it is believed that changing the terminology will shift the focal point of the disorder from chronic use, tolerance, and withdrawal to the detrimental effects of the disorder to the person, their family, and occupation (Potenza, 2006). In addition to supporting this change in nomenclature, some researchers have argued that the scope of addictions should be extended beyond SUD's to include behavioural addictions, such as pathological gambling and sexual, internet, and shopping addictions (Goodman, 2001; Martin & Petry, 2005).
This increased pressure for the conceptualization of behaviours as potentially addictive is heavily supported by research highlighting the neurobiological similarities between impulse control disorders and substance addictions (Holden, 2001). There is a growing body of literature suggesting that the brain circuitry implicated in substance addictions-namely, the ventromedial prefrontal cortex and the dopaminergic mesolimbic pathway linking the ventral tegmental area to the nucleus accumbens, or as it is commonly referred to as, the "reward system"-is involved in impulse control disorders such as PG (Potenza, 2006). For example, in one study, a decreased activation of the ventral striatal and ventromedial prefrontal cortex was observed in people with PG during the presentation of gambling-related cues (Reuter, Raedler, Rose, Hand, Gläsche, & Büchel, 2005), a neurological finding that is consistent with research on people with SUD's.
Using Shaffer's (1999) definition of addiction ((1) craving state prior to behavioural engagement, or a compulsive engagement; (2) impaired control over behavioural engagement; and (3) continued behavioural engagement despite repeated adverse consequences) it could be argued that most, if not all, of the people identified in clinical samples as presenting symptoms consistent with CBD meet the criteria for an addiction. For example, they have preoccupations with buying items (1); irresistible urges and impulses to buy which can only be alleviated following a purchase (2); and a continuation of excessive spending despite personal, familial, occupational, and financial problems that are caused by, or at least in some way related to, the behaviour (3) (Black, 2001; Black, 2007; Dell'Osso, Allen, Altamura, Buoli, & Hollander, 2008).
Option 2: CBD as an Obsessive-Compulsive Disorder
Another categorical change being considered for the DSM-V is the creation of an obsessive-compulsive spectrum disorder (OCSP) category. This proposed revision reflects the recent shift in the literature from a categorical to a dimensional conceptualization of psychopathology. In light of this proposed change, some have argued that CBD should be placed along the obsessive-compulsive spectrum, with compulsive disorders, such as OCD, at one end and impulsive disorders, such as PG and CBD, at the other. The rationale for this is that people with CBD, like OCD, are preoccupied with persistent and intrusive thoughts about buying items, which causes anxiety and motivates the person to shop in order to alleviate the anxiety (Ridgway, Kukar-Kinney, & Monroe, 2008).
While obsessive-compulsive tendencies have been associated with CBD, people with this condition also score high on the personality traits impulsivity and sensation seeking and low on the trait conscientiousness (Rodriguez-Villarino et al., 2006). These personal variables are uncharacteristic of most individuals with OCD. Furthermore, there are several other significant differences between impulsive and compulsive disorders that are worth noting. For example, in compulsive disorders the thoughts tend to be egodystonic and the disorder is characterized by overestimation of harm, harm avoidance, risk aversion, and anticipatory anxiety (Dell'Osso et al., 2006). Conversely, in impulsive disorders the thoughts tend to be egosyntonic and the disorder is characterized by underestimation of harm and risk seeking. Moreover, the behaviours in impulse control disorders produce pleasurable and gratifying feelings, whereas the compulsive behaviours common in OCD are not pleasurable; in fact, they are often embarrassing, distressing, painful (i.e., excessive hand washing), and the primary motivation is to alleviate anxiety caused by obsessive and intrusive thoughts. The DSM-IV-TR (American Psychiatric Association, 2000) clearly defines compulsions as:
repetitive behaviours (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) the goal of which is to prevent or reduce anxiety or distress, not to provide pleasure or gratification [italics added]. In mostcases, the person feels driven to perform the compulsion to reduce the distress that accompanies an obsession or to prevent some dreaded event or situation (p. 457).
Although anxiety may, and often does, precede an impulsive act, such as excessive shopping, the pleasurable feelings associated with the act also contribute significantly to its motivation, which precludes the behaviour from being classified as an OCD.
Other support for the designation of CBD as an OCSD has come from the high comorbidity rates (about 35%) of OCD in impulse control disorders (Fontenelle, Mendlowicz, & Versiani, 2005). However, this is tenuous evidence, not suffice to warrant the inclusion of impulse control disorders into the OCSD category. The comorbidity rates of anxiety in depression, eating disorders, and SUD's are high as well; does this mean that these disorders should be merged into one dimensional category?
Option 3: CBD an Impulse Control Disorder
The DSM-IV-TR includes the following description of impulse control disorders:
The essential feature of Impulse-Control Disorders is the failure to resist an impulse, drive, or temptation to perform an act that is harmful to the person or to others. For most of the disorders in this section, the individual feels an increasing sense of tension or arousal before committing the act and then experiences pleasure, gratification, or relief at the time of committing the act (APA, 2000, p. 663).
The DSM's description of an impulse control disorder seems to accurately characterize the core features of CBD. People with this disorder report an irresistible impulse or urge to shop. Moreover, after engaging in the act of buying something they report feeling a sense of gratification or relief.
One could argue, however, that substance dependence, barring the withdrawal and tolerance criteria, could be classified as an impulse control disorder. Goodman (2001) has made the argument that, "If substance dependence, which is readily acknowledged to be an addictive disorder, is also an impulse control disorder, then a condition that meets the diagnostic criteria for impulse-control disorder is not thereby precluded from also being identified as an addictive disorder" (p. 194). Granted, there are marked similarities between the concepts "addiction" and "impulse control". However, according to this viewpoint, any behaviour, such as eating, exercise, watching TV, setting fires, and stealing could be "technically" classified as an "addiction", which would trivialize the entire concept of the disorder. One has to question whether this is a path that psychology, a scientific discipline, should be heading down. Goodman's (2001) opinions, as anchored in research as they may be, reflect scientist's tendency to "pathologize" any deviant behaviour. Indeed, this is one of the criticisms of employing the term addiction and why the DSM task force has been so reluctant to include the term into its nomenclature.
Conclusions
Compulsive buying is indisputably a debilitating behaviour with severe consequences for the person and their family. People with CBD clearly exhibit the "three D's" of psychopathology: their behaviour is distressing, dysfunctional, and deviant. It appears that shopping in people with CBD is as a way of improving, if only temporarily, their negative moods. The abnormally high comorbidity rates in CBD suggest that people afflicted with this disorder have other underlying psychological and emotional problems that need to be addressed with therapy and/or medication. It is therefore concluded that CBD should be acknowledged by the DSM as a mental disorder and classified as an impulse control disorder (ICD) not otherwise specified (NOS). This will ensure that people experiencing these problems can be referred to therapy where they can receive a diagnosis and treatment. The DSM-V should list CBD as an example of an ICD-NOS so that therapists specifically, and the public generally, are aware of the fact that it is recognized as a mental disorder.
Although there are many clinical and neurobiological similarities between impulse control disorders and SUD's, labelling CBD as an addiction is problematic. CBD appears to be a manifestation of other recognized psychological problems rather than its own individual mental disorder. The excessive shopping in CBD is not so much the problem as is the high levels of depression, anxiety, and SUD's, and the person's poor stress-coping mechanisms, all of which contribute to the person's behaviour.
OCD is a heterogeneous disorder and, as such, its symptomology may be better understood if it is conceptualized as a dimensional, rather than a categorical, disorder (Castle & Phillips, 2006). However, there is simply not enough evidence to warrant the inclusion of CBD into the obsessive-compulsive spectrum. Furthermore, the research that is available suggests that compulsive behaviours, albeit similar in some respects to impulsive behaviours, are primarily engaged in to alleviate anxiety, not to produce pleasure. As such, the two disorders should be classified as separate psychiatric conditions.
To the average layperson, the classification of a mental disorder, such as CBD, may seem unimportant. After all, what's in a word? But the nosology of a mental disorder has profound and far-reaching implications for patients, researchers, therapists, and society as a whole.
From the perspective of the person with the disorder, if their excessive buying is deemed an addiction, which has a strong disease-like connotation, they may feel as though they are absolved from any legal or financial responsibility for their behaviour. From the perspective of treatment, it's more likely that the patient's symptoms will improve if they believe that their behaviour is as an impulse control disorder rather than an addiction. For example, if CBD is diagnosed as an addiction and treated as such, how is one to go about abstaining, which is the universally accepted and recommended treatment for addictions, from shopping or buying? The nosology of CBD even has implications at the societal level. For example, if CBD is labelled as an impulse control disorder rather than an addiction, the public may feel that punishment is a more appropriate response to the behaviour than treatment (Goodman, 2001).
Clearly, then, the classification of a mental disorder is not just a matter of terminology. Words are important and the ones that should be employed by the DSM to refer to CBD are "Impulse control disorder not otherwise specified".
Although not officially recognized as a mental disorder, compulsive buying is a serious and chronic problem that causes significant impairments in social, occupational, and interpersonal areas of functioning. In anticipation of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V), many researchers have argued for the acknowledgement of this condition as a mental disorder. In addition to reviewing the extant research on compulsive buying and the evidence supporting its validity as a mental illness, this paper explores the possible classifications of the disorder in the context of proposed revisions to the DSM-V. Although more research is needed to elucidate the nature of the disorder, it is concluded that CBD should be classified as an impulse control disorder, rather than an addiction or obsessive-compulsive disorder.
Compulsive buying disorder (CBD): Conceptualization and classification
The DSM task force is busy preparing for the publication of its 5th edition of the Diagnostic and Statistical Manual of Mental Disorders, which is set to be released sometime in May, 2013 (American Psychiatric Association, 2010). In anticipation of its release, there has been a surge in research evaluating the current organization and classification of mental disorders in the DSM-IV-TR and several recommendations have been made for the 5th edition. Perhaps the most notable, and indeed the most controversial, revision being considered for the DSM-V is the introduction of several new disorders. One of the disorders being considered for inclusion is Compulsive Buying Disorder (CBD) . Below is a review of the extant research on CBD, including its symptomology, epidemiology, comorbidity, and possible classifications if and when it is included into the DSM.
Compulsive Buying Disorder (CBD): Definition, clinical symptoms, epidemiology, and comorbidity
Although it is not included in the DSM-IV-TR (American Psychiatric Association, 2000), Compulsive Buying Disorder (CBD) has received considerable attention in the literature since the 1990's, when clinical case studies first started to appear (McElroy, Keck, Pope et al., 1994; Schlosser, Black, Repertinger, & Freet, 1994). Currently, people presenting symptoms consistent with CBD are diagnosed with "Impulse Control Disorder Not Otherwise Specified". However, the classification of the disorder has been a topic of much debate. Notwithstanding this disagreement over the nosology of CBD, there is a general consensus within the literature that it is a serious condition (Hartson & Horan, 2002) characterized by excessively or poorly controlled preoccupations, urges, or behaviours with regard to shopping or buying (Black, 2001), which can lead to negative consequences such as remorse, excessive debt, marital and family conflict and even suicide attempts (O'Guinn & Faber, 1989; McElroy et al., 1997; Koran, Faber, Aboujaoude, Large, & Serpe, 2006).
The diagnostic criteria for CBD proposed by McElroy et al. (1994) has received widespread acceptance among researchers and has been used in several studies as a threshold for the disorder (see Appendix A for McElroy et al. (1994) diagnostic criteria for CBD). The core elements of the criteria include: (1) Frequent preoccupation with shopping or intrusive, irresistible, 'senseless' buying impulses; (2) clearly buying more than is needed or can be afforded; (3) distress related to buying behaviour; and (4) significant interference with work or social functioning.
The estimated prevalence of CBD in the adult U.S. population is about 5.8% (Koran et al., 2006), although prevalence rates as low 1.8% (Faber & O'Guinn, 1989) and as high as 8% (Magee, 1991) have been reported in the literature. Caution must be exercised, however, when interpreting such prevalence rates because, other than McElroy et al. (1994) proposed criteria which was based on 20 reported cases, CBD currently lacks a definitive criteria.
The age of onset for CBD appears to be in the late teens to early 20's (Black, 2001). The preponderance of people identified as compulsive buyers are female, constituting, on average, 80-95% of clinical samples (Schlosser et al., 1994; McElroy et al., 1994). However, a recent study (Koran et al., 2006) using a large general population sample found that the prevalence rates of CBD between men and women were only marginally different. The disparity between gender rates of CBD in clinical and community samples may be explained by female's greater willingness than men to seek therapy for their compulsive shopping.
Comorbidity rates among people with CBD are exceedingly high (McElroy et al., 1994; Schlosser et al., 1994). Among the Axis I disorders commonly associated with CBD are mood, anxiety, substance use and eating disorders. In Schlosser et al. (1994) clinical sample of 46 people with CBD, 60% met the criteria for at least one personality disorder, most commonly obsessive compulsive (22%). Furthermore, first-degree relatives (FDRs) of individuals with CBD are more likely to have psychiatric disorders such as alcohol or substance abuse, major depression, and anxiety disorders than FDRs of people without CBD (McElroy et al., 1994; Black et al., 1998).
Four distinct phases of CBD have been identified (Black, 2007): 1) anticipation; 2) preparation; 3) shopping; and 4) spending. In the first phase, the person has thoughts or preoccupations with having a certain item or shopping in general. The second phase involves preparing for shopping which may include deciding at which store to shop, what clothes to wear, and even which credit card to use. The third phase involves the actual act of shopping. Many people with CBD have reported that they feel exhilarated when shopping and in some this may lead to sexual feelings (Schlosser et al., 1994). Finally, the last phase involves the purchasing of the item, after which the person may be overwhelmed with feelings of shame and embarrassment (Hartston & Koran, 2002). Clothes, shoes, jewellery, and makeup are among the most common items purchased by women, whereas men are more likely to purchase electronic, hardware, and automotive products (Black, 2001; Black, 2007).
In a study exploring the antecedents and consequences of compulsive buying, Miltenberger et al. (2003) found that negative emotions such as depression, anxiety, boredom, and self-critical thoughts were common antecedents to compulsive buying, whereas euphoria and relief of negative emotions were often consequences. Thus, in individuals with CBD, shopping appears to be a primary response to stress (O'Guinn & Faber, 1989) and used as a means of mood elevation (Clark & Calleja, 2008). The pleasurable feelings associated with shopping in people with CBD are positively reinforcing and the alleviation of anxiety and depressed mood is negatively reinforcing, both of which serve to perpetuate the behaviour.
Research has consistently found that people who buy compulsively display higher rates of the compulsive personality trait, have lower self-esteems, depressed moods, more compromised self-perceptions and perfectionistic expectations, more decision making difficulties, and are more prone to fantasy than people with more normal buying behaviour (O'Guinn & Faber, 1989; Kyrios, Frost, & Steketee, 2004). Rose (2007) reported a positive correlation between narcissism, materialism, and compulsive buying, and a negative association between impulse control and each of these variables in people with CBD.
Criticism of CBD
Although many researchers have argued for the inclusion of CBD into the DSM, some feel that it is not a bona fide mental illness (Shirley & Avis, 2004). Compulsive shopping, they argue, and other similar controversial disorders such as "internet" and "sex addictions" are moral, rather than medical, problems. They also criticize the medical and scientific community's eagerness to "medicalize" deviant behaviour, which they perceive as attempts to create more conditions to treat with pharmaceutical drugs. Similar criticisms have been made towards attention deficit hyperactivity disorder (ADHD) and social anxiety disorder, which some argue are just normal traits that have been ascribed medical labels and treated with drugs (Hollander, 2006). However, creating a new diagnosis is a complex process, and much of the attack directed at the validity of certain mental disorders has come from armchair critics.
Granted, the line between "excessive" and "compulsive" or "disordered" buying is arbitrary at best, but this is true of most, if not all, mental disorders in the DSM. Moreover, the clinical emphasis of CBD is not on the amount of the behaviour-many people in our culture of consumerism shop "excessively" or purchase items that they don't need-but rather the consequences of the behaviour. Asserting that conditions such as CBD, ADHD, and social phobia are "trivial" disorders, not worthy of diagnosis and treatment undermines the serious social, occupational, and interpersonal disruptions that these disorders often cause when untreated. Others have pointed out that including a disorder into the DSM, even if it is seemingly "trivial" or controversial, is very important for augmenting knowledge about that particular condition because it provides researchers with a specific set of criteria to use in their research (Hollander, 2006), which can then be used to refine and improve the disorder's criteria.
Compulsive Buying Disorder: Classification
Though it may not seem that important, the nosology of a mental disorder has profound implications. As mentioned previously, CBD is not currently recognized by the DSM-IV-TR as a mental disorder and, as such, the classification of CBD, upon inclusion into the DSM, has been a topic of much debate among researchers investigating the disorder. Three possible classifications for CBD have been proposed.
Option 1: CBD as an Addictive Disorder
The rationale behind classifying some impulse control disorders, such as compulsive shopping and pathological gambling (PB), as behavioural addictions is that they share many important features-clinical symptoms, comorbidity, family history, brain circuitry, and treatment responses to SSRI's-with substance addictions (Bernardo et al., 2008; Hollander, 2009).
Currently, the nomenclature of the DSM-IV-TR lacks the term "addiction". However, one of the proposed revisions being considered for the DSM-V is the removal of the "substance use disorder" (SUD) section and the adoption of an "addiction and related disorders" category. Many researchers have advocated for the complete abolishment of the terms "substance" and "dependence", as research has shown that these terms are misleading and problematic. For example, tolerance and withdrawal are generally considered to be the trademark symptoms of substance dependence, but people can become tolerant to and experience withdrawal symptoms from a drug without necessarily being addicted to it.
Thus, it is believed that changing the terminology will shift the focal point of the disorder from chronic use, tolerance, and withdrawal to the detrimental effects of the disorder to the person, their family, and occupation (Potenza, 2006). In addition to supporting this change in nomenclature, some researchers have argued that the scope of addictions should be extended beyond SUD's to include behavioural addictions, such as pathological gambling and sexual, internet, and shopping addictions (Goodman, 2001; Martin & Petry, 2005).
This increased pressure for the conceptualization of behaviours as potentially addictive is heavily supported by research highlighting the neurobiological similarities between impulse control disorders and substance addictions (Holden, 2001). There is a growing body of literature suggesting that the brain circuitry implicated in substance addictions-namely, the ventromedial prefrontal cortex and the dopaminergic mesolimbic pathway linking the ventral tegmental area to the nucleus accumbens, or as it is commonly referred to as, the "reward system"-is involved in impulse control disorders such as PG (Potenza, 2006). For example, in one study, a decreased activation of the ventral striatal and ventromedial prefrontal cortex was observed in people with PG during the presentation of gambling-related cues (Reuter, Raedler, Rose, Hand, Gläsche, & Büchel, 2005), a neurological finding that is consistent with research on people with SUD's.
Using Shaffer's (1999) definition of addiction ((1) craving state prior to behavioural engagement, or a compulsive engagement; (2) impaired control over behavioural engagement; and (3) continued behavioural engagement despite repeated adverse consequences) it could be argued that most, if not all, of the people identified in clinical samples as presenting symptoms consistent with CBD meet the criteria for an addiction. For example, they have preoccupations with buying items (1); irresistible urges and impulses to buy which can only be alleviated following a purchase (2); and a continuation of excessive spending despite personal, familial, occupational, and financial problems that are caused by, or at least in some way related to, the behaviour (3) (Black, 2001; Black, 2007; Dell'Osso, Allen, Altamura, Buoli, & Hollander, 2008).
Option 2: CBD as an Obsessive-Compulsive Disorder
Another categorical change being considered for the DSM-V is the creation of an obsessive-compulsive spectrum disorder (OCSP) category. This proposed revision reflects the recent shift in the literature from a categorical to a dimensional conceptualization of psychopathology. In light of this proposed change, some have argued that CBD should be placed along the obsessive-compulsive spectrum, with compulsive disorders, such as OCD, at one end and impulsive disorders, such as PG and CBD, at the other. The rationale for this is that people with CBD, like OCD, are preoccupied with persistent and intrusive thoughts about buying items, which causes anxiety and motivates the person to shop in order to alleviate the anxiety (Ridgway, Kukar-Kinney, & Monroe, 2008).
While obsessive-compulsive tendencies have been associated with CBD, people with this condition also score high on the personality traits impulsivity and sensation seeking and low on the trait conscientiousness (Rodriguez-Villarino et al., 2006). These personal variables are uncharacteristic of most individuals with OCD. Furthermore, there are several other significant differences between impulsive and compulsive disorders that are worth noting. For example, in compulsive disorders the thoughts tend to be egodystonic and the disorder is characterized by overestimation of harm, harm avoidance, risk aversion, and anticipatory anxiety (Dell'Osso et al., 2006). Conversely, in impulsive disorders the thoughts tend to be egosyntonic and the disorder is characterized by underestimation of harm and risk seeking. Moreover, the behaviours in impulse control disorders produce pleasurable and gratifying feelings, whereas the compulsive behaviours common in OCD are not pleasurable; in fact, they are often embarrassing, distressing, painful (i.e., excessive hand washing), and the primary motivation is to alleviate anxiety caused by obsessive and intrusive thoughts. The DSM-IV-TR (American Psychiatric Association, 2000) clearly defines compulsions as:
repetitive behaviours (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) the goal of which is to prevent or reduce anxiety or distress, not to provide pleasure or gratification [italics added]. In mostcases, the person feels driven to perform the compulsion to reduce the distress that accompanies an obsession or to prevent some dreaded event or situation (p. 457).
Although anxiety may, and often does, precede an impulsive act, such as excessive shopping, the pleasurable feelings associated with the act also contribute significantly to its motivation, which precludes the behaviour from being classified as an OCD.
Other support for the designation of CBD as an OCSD has come from the high comorbidity rates (about 35%) of OCD in impulse control disorders (Fontenelle, Mendlowicz, & Versiani, 2005). However, this is tenuous evidence, not suffice to warrant the inclusion of impulse control disorders into the OCSD category. The comorbidity rates of anxiety in depression, eating disorders, and SUD's are high as well; does this mean that these disorders should be merged into one dimensional category?
Option 3: CBD an Impulse Control Disorder
The DSM-IV-TR includes the following description of impulse control disorders:
The essential feature of Impulse-Control Disorders is the failure to resist an impulse, drive, or temptation to perform an act that is harmful to the person or to others. For most of the disorders in this section, the individual feels an increasing sense of tension or arousal before committing the act and then experiences pleasure, gratification, or relief at the time of committing the act (APA, 2000, p. 663).
The DSM's description of an impulse control disorder seems to accurately characterize the core features of CBD. People with this disorder report an irresistible impulse or urge to shop. Moreover, after engaging in the act of buying something they report feeling a sense of gratification or relief.
One could argue, however, that substance dependence, barring the withdrawal and tolerance criteria, could be classified as an impulse control disorder. Goodman (2001) has made the argument that, "If substance dependence, which is readily acknowledged to be an addictive disorder, is also an impulse control disorder, then a condition that meets the diagnostic criteria for impulse-control disorder is not thereby precluded from also being identified as an addictive disorder" (p. 194). Granted, there are marked similarities between the concepts "addiction" and "impulse control". However, according to this viewpoint, any behaviour, such as eating, exercise, watching TV, setting fires, and stealing could be "technically" classified as an "addiction", which would trivialize the entire concept of the disorder. One has to question whether this is a path that psychology, a scientific discipline, should be heading down. Goodman's (2001) opinions, as anchored in research as they may be, reflect scientist's tendency to "pathologize" any deviant behaviour. Indeed, this is one of the criticisms of employing the term addiction and why the DSM task force has been so reluctant to include the term into its nomenclature.
Conclusions
Compulsive buying is indisputably a debilitating behaviour with severe consequences for the person and their family. People with CBD clearly exhibit the "three D's" of psychopathology: their behaviour is distressing, dysfunctional, and deviant. It appears that shopping in people with CBD is as a way of improving, if only temporarily, their negative moods. The abnormally high comorbidity rates in CBD suggest that people afflicted with this disorder have other underlying psychological and emotional problems that need to be addressed with therapy and/or medication. It is therefore concluded that CBD should be acknowledged by the DSM as a mental disorder and classified as an impulse control disorder (ICD) not otherwise specified (NOS). This will ensure that people experiencing these problems can be referred to therapy where they can receive a diagnosis and treatment. The DSM-V should list CBD as an example of an ICD-NOS so that therapists specifically, and the public generally, are aware of the fact that it is recognized as a mental disorder.
Although there are many clinical and neurobiological similarities between impulse control disorders and SUD's, labelling CBD as an addiction is problematic. CBD appears to be a manifestation of other recognized psychological problems rather than its own individual mental disorder. The excessive shopping in CBD is not so much the problem as is the high levels of depression, anxiety, and SUD's, and the person's poor stress-coping mechanisms, all of which contribute to the person's behaviour.
OCD is a heterogeneous disorder and, as such, its symptomology may be better understood if it is conceptualized as a dimensional, rather than a categorical, disorder (Castle & Phillips, 2006). However, there is simply not enough evidence to warrant the inclusion of CBD into the obsessive-compulsive spectrum. Furthermore, the research that is available suggests that compulsive behaviours, albeit similar in some respects to impulsive behaviours, are primarily engaged in to alleviate anxiety, not to produce pleasure. As such, the two disorders should be classified as separate psychiatric conditions.
To the average layperson, the classification of a mental disorder, such as CBD, may seem unimportant. After all, what's in a word? But the nosology of a mental disorder has profound and far-reaching implications for patients, researchers, therapists, and society as a whole.
From the perspective of the person with the disorder, if their excessive buying is deemed an addiction, which has a strong disease-like connotation, they may feel as though they are absolved from any legal or financial responsibility for their behaviour. From the perspective of treatment, it's more likely that the patient's symptoms will improve if they believe that their behaviour is as an impulse control disorder rather than an addiction. For example, if CBD is diagnosed as an addiction and treated as such, how is one to go about abstaining, which is the universally accepted and recommended treatment for addictions, from shopping or buying? The nosology of CBD even has implications at the societal level. For example, if CBD is labelled as an impulse control disorder rather than an addiction, the public may feel that punishment is a more appropriate response to the behaviour than treatment (Goodman, 2001).
Clearly, then, the classification of a mental disorder is not just a matter of terminology. Words are important and the ones that should be employed by the DSM to refer to CBD are "Impulse control disorder not otherwise specified".