Successful Treatment with Fluvoxamine and Cognitive ... - MedIND

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DELHI PSYCHIATRY JOURNAL Vol. 13 No.1

Case Report

Oniomania – Successful Treatment with Fluvoxamine and Cognitive-Behavioral Psychotherapy Anurag Jhanjee*, Pankaj Kumar*, M.S. Bhatia*, Shruti Shrivastava*, Nishit Bhatnagar*, Vivek Kumar** *Department of Psychiatry, U.C.M.S & G.T.B. Hospital, Delhi, University of Delhi **Department of Psychiatry, Safdarjung Hospital, Delhi

Introduction

Case Report 1

Compulsive buying (oniomania), a DSM-IV impulse-control disorder not otherwise specified, is characterized by preoccupation with shopping and inability to resist buying unneeded items, with resulting marked distress, social or occupational impairment, and financial and/or familial problems. Although little attention has been paid until recently to compulsive buying, the entity was recognized by both Emil Kraepelin and Eugen Bleuler2. It was originally referred to as oniomania and categorized as one of the “reactive impulses” or “impulsive insanities.” Pathological or compulsive buying is defined as frequent preoccupation with buying or as impulses to buy that are experienced as irresistible, intrusive, and/or senseless. The buying behavior causes marked distress, interferes with social functioning, and often results in financial problems. Pathological buying should be diagnosed as impulse control disorder not otherwise specified (ICD-10 F63.9). Psychiatric co morbidity is frequent, particularly mood, anxiety, substance use, eating, impulse control and obsessive-compulsive disorders3. The positive results of pharmacological treatment with antidepressants (usually SSRI) Lejoyeux,6 McElroy,7 Ninan8 and opioid antagonists (Kim9) could not be confirmed in controlled trials. We present the case of a 36-year old woman with a history of excessive pathological buying. According to the assumption that addiction is a learned behavior, we assume that for the patient, compulsive buying as a rewarding behavior has the function of an inadequate stress coping strategy.

A 36-year-old single woman, a lecturer by profession, belonging to middle socio-economic status presented to our psychiatry OPD for help after several months of increasing shopping binges. Although the patient’s spending had not been a problem in the past, she could no longer control it now, despite increasingly limited funds. At first, she only bought jewelry but soon became so caught up in the action that she found herself impulsively buying objects that she neither needed nor wanted. Over a period of few months of indiscriminate spending, she had exhausted her financial resources completely, leaving her extremely distressed and even then she couldn’t control her impulse to spend. Consequently she resorted to borrowing money from people and ran up large debts. Her relationship, friendships and professional activities deteriorated. She continued to spend more and more on credit card purchases, generally items of clothing and jewelry for herself. She was extremely attracted to the lights and smells of a particular clothing designer. Despite numerous attempts to control her spending, she was unable to resist the impulse to shop. When she limited her visits to shopping malls, she turned to the home shopping network and continued to build a large debt. She described experiencing a sense of tension before shopping and a sense of relief while she did shopping. Shortly afterward, however, she felt quite remorseful with the realization that she could not control herself and that this behavior was becoming a great problem for her family. The patient and her family members were psycho educated about the nature of patient’s

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illness and about the available therapeutic options and after thorough discussion with them, a treatment plan was formulated. The treatment consisted of a combination of individual cognitive-behavioral psychotherapy and psychopharmacology. She was placed on fluvoxamine (100 mg, up to twice a day) to treat her continued dysphoric feelings and obsessive rituals of shopping. Over the next few weeks, she was able to curtail her uncontrolled shopping greatly. During a 12-month follow-up period, she didn’t have compulsive buying episode and returned to normal life activities. Combined therapy produced rapid, marked, sustained improvements on both the Yale-Brown Obsessive Compulsive Scale-Shopping Version (YBOCS-SV)10 and the Clinical Global Impressions-Improvement (CGI-I) scale in patient. Discussion and Conclusion Impulse-control disorders include a diverse group of conditions characterized by excessive thoughts or preoccupations combined with poorly controlled behaviors. They include trichotillomania, kleptomania, pathologic gambling, compulsive buying disorder, compulsive sexual behavior, and compulsive computer use. Some investigators (Black11 , Koran12 ) have suggested that these conditions constitute a spectrum of disorders linked to obsessive-compulsive disorder. Others (Schlosser et al.,5 Glatt13) have questioned the validity of this conceptualization, and have debated the relationship between these disorders. Although not recognized by DSM-IV14 or ICD10 as a unique subcategory of the impulse-control disorders, some attempt has been made to develop a formal definition and diagnostic criteria of compulsive buying for both research and clinical purposes, based on the phenomenology of cases in the literature to date (Table 1). There are no evidence-based treatments for compulsive buying disorder. In recent years, treatment studies of compulsive buying disorder have focused on the use of psychotropic medication (mainly antidepressants) and cognitive-behavioral therapy (CBT). Serotonin reuptake inhibitors remain the best studied pharmacologic treatment, but researchers have also explored other antidepressants, opioid agonists, mood stabilizers, and atypical antipsychotics. 148

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Table-1. Diagnostic Criteria for Compulsive Buying A. Maladaptive preoccupation with buying or shopping, or maladaptive buying or shopping impulses or behavior, as indicated by at least one of the following: 1. Frequent preoccupation with buying or impulses to buy that is experienced as irresistible, intrusive, and/or senseless. 2. Frequent buying of more than can be afforded, frequent buying of items that are not needed, or shopping for longer periods of time than intended. B. The buying preoccupations, impulses, or behaviors cause marked distress, are time consuming, significantly interfere with social or occupational functioning, or result in financial problems (e.g., indebtedness or bankruptcy). C. The excessive buying or shopping behavior does not occur exclusively during periods of hypomania or mania. McElroy SL et al13 Psychopharmacologic treatment studies have yielded mixed results. McElroy et al.14 first reported benefit from antidepressant therapy in three cases of Compulsive Buying Disorder with comorbid depression and anxiety. In a retrospective chart review, McElroy’s14 group reported on 20 patients who benefited from antidepressants, often in combination with mood stabilizers. Lejoyeux 6 reported on two patients in whom the treatment of a comorbid mood disorder led to remission of compulsive buying behavior. Black 15 reported fluvoxamine to be effective in the patients without comorbid major depression, suggesting that improvement was independent of the treatment of mood symptoms. Kim9 reported improvement with naltrexone, an opioid antagonist, in a case series. Two double-blind placebo-controlled trials found fluvoxamine no better than placebo; however, in both studies patients kept shopping logs, which may have confounded the results. An open-label trial of citalopram and a double-blind crossover trial which excluded shopping logs, both reported positive results. Twelve-month follow-up data for the openlabel group found that remission rates at quarterly time points were independent of continuing drug therapy.


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Compulsive buying in our case was characterized by repetitive compulsive and excessive misappropriated buying. Labels for this pathological behavior vary and its classification is uncertain. To date, there is no consistent concept for diagnosis and treatment, which is a problem in clinical practice. 3,5 Therefore, in this case the diagnosis “compulsive buying” is appropriate. This diagnosis is important for the choice of the therapeutic intervention, which is in accordance to the current therapeutic interventions for impulse-control disorder. In our case, fluvoxamine proved to be a safe and effective treatment for compulsive buying in combination with cognitive behavior therapy. The available r esearch data suggests that pharmacological interventions may be effective for compulsive buying disorder. Whether pharmacological treatment is superior to placebo and whether it is more, less or equally effective compared to psychotherapeutic interventions remains to be established. We hope that future research in the area of psychopharmacology may one day provide us with evidence-based treatment for compulsive buying disorder. References 2. Bleuler E. Textbook of psychiatry. New York:McMillan, 1930. 3. Black DW. Compulsive buying: a review. J Clin Psychiatry 1996; 57 Suppl. 8: 50-5. 4. Christenson GA, Faber JR, de Zwann M. Compulsive buying: descriptive characteristics and psychiatric comorbidity. J Clin Psychiatry 1994; 55 (1): 5-11. 5. Black DW et al. Compulsive buying disorder – definition, assessment, epidemiology and clinical management. CNS Drugs 2001; 15 (1): 17-27. 5. Schlosser S, Black DW, Repertinger S, et al. Compulsive buying: demography, phenomenology, and comorbidity in 46 subjects. Gen Hosp Psychiatry 1994; 16: 205-12.

6. Lejoyeux M, Tassian V, Solomon J. Study of compulsive buying in depressed patients. J Clin Psychiatry 1997; 58 (4): 169-73. 7. McElroy SL, Keck Jr PE, Pope Jr HG, et al. Compulsive buying: a report of 20 cases. J Clin Psychiatry 1994; 55 (6): 242-8. 8. Ninan PT,McElroy SL, Kane CP, et al. Placebo controlled study of fluvoxamine in the treatment of patients with compulsive buying. J Clin Psychopharmacol 2000; 20: 362-6. 9. Kim SW. Opioid antagonists in the treatment of impulse-control disorders. J Clin Psychiatry 1998; 59 : 159-64. 10. Monahan P, Black DW, Gabel J. Reliability and validity of a scale to measure change in persons with compulsive buying. Psychiatry Res 1995; 64:59-67. 11. Black DW. The obsessive-compulsive spectrum: fact or fancy? In: MajM, Sartorius N, Okasha A, et al., editors. Obsessive compulsive disorders. New York: John Wiley, 2000: 233-5. 12. Koran L. Obsessive compulsive and related disorders in adults. New York: Cambridge University Press, 1999. 13. Glatt MM, Cook CC. Pathological spending as a form of psychological dependence. Br J Addict 1987; 82 : 1252-8. 14. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th ed. Washington, DC: American Psychiatric Press, 1994. 15. McElroy S, Satlin A, Pope Jr HG, et al. Treatment of compulsive shopping with antidepressants: a report of three cases. Ann Clin Psychiatry 1991; 3 (3): 199-204. 16. Black DW, Monahan P, Gabel J. Fluvoxamine in the treatment of compulsive buying. J Clin Psychiatry 1997; 58 (4): 159-63.


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