Behavioral Addictions _ _______________________________________________________________________
PATHOGENESIS AND PATHOPHYSIOLOGY A breakthrough in the understanding of the pathogenesis of compulsive buying disorder came from Parkinson disease studies, in which some patients prescribed dopaminergic agents developed compulsive buying behavior. This suggests dopamine plays a role in compulsive buying, similar to sub- stance use disorders. This parallel to substance addiction is supported by the finding that the brain does not distinguish between dopamine release in the nucleus accumbens and ventral tegmental area secondary to drug use or experience (like shopping) [295]. Furthermore, functional neuroimaging studies have shown that shopping activates many of the same brain regions as drugs of abuse, specifically the mesocortico- limbic system and the amygdala [296]. Evidence suggests that behavioral addictions may lead to neuroadaptations similar to those reported with substance use disorder, including a hijacking of the neural circuits responsible for the natural reward pathways. If a drug or experience is hyperstimulating, this neuroadaptation (namely, down-regulation of dopamine receptors) occurs with repeated exposures [282]. Different emotional (e.g., pleasure seeking, escape of negative emotions) and cognitive (e.g., impulsivity, self-regulation, decision-making deficits) mechanisms contribute to the devel- opment and maintenance of compulsive buying disorder. A growing number of researchers emphasize that compulsive buying disorder shares several key characteristics with other behavioral addictions, including preoccupation with the behavior, diminished control over the behavior, repeated unsuccessful attempts to cut down or stop the behavior, toler- ance, withdrawal, and adverse psychosocial consequences. Importantly, cue-reactivity and craving has been demonstrated in individuals with compulsive buying disorder [294]. As dis- cussed, Internet characteristics seem to encourage compulsive buying, with greater and more rapid excitation, gratification and reward response, buying opportunity 24 hours per day, buying from the convenience of home, and easy payment that can lead to unplanned overspending [294]. Brain imaging studies of compulsive buying disorder and other behavioral addictions have consistently found frontoparietal region, reward processing, and limbic system abnormalities, also commonly observed in substance use disorders [280]. Neurocognitive data suggest that subjects with compulsive buying disorder have impairments in response inhibition, risk adjustment during decision-making, and spatial working memory. Problems in these distinct cognitive domains support a neurobiologic overlap between compulsive buying and other behavioral and substance addictions [85]. As discussed, Gray’s reinforcement sensitivity theory states that a hyper-responsive behavioral system predisposes individuals to engage in impulsive behaviors [297]. It has also been used to explain the addictive processes underlying compulsive buying disorder; both reinforcement and punishment systems seem to participate in the onset and development of this disorder [298]. Dysfunctional emotional regulation is also implied in the phenotype of behavioral addictions, particularly in aspects such as managing cravings and withdrawal symptoms [280].
Research indicates that individuals with high reward sensitiv- ity are motivated to engage in behaviors that provide internal reinforcement (enhancement/winning motives) and external reinforcement (social motives). Similarly, greater compulsive buying tendencies have been positively associated with reward sensitivity, which has been reported to be a powerful predictor of disorder severity [46; 299]. College students meeting the criteria for compulsive buying have shown greater psychiatric comorbidity, increased stress, and worse physical health [46]. Individuals with greater pun- ishment sensitivity are vulnerable to negative emotions (e.g., frustration, anxiety, fear, sadness), and compulsive buying may serve as a form of negative reinforcement [46]. DIAGNOSIS Compulsive buying disorder is characterized by a maladaptive preoccupation with buying and shopping and by repetitive purchasing of consumer goods to relieve stress, to escape from negative feelings, and to enhance a poor sense of self [285]. These patients engage in persistent, excessive, impulsive, and uncontrollable purchase of products despite severe psy- chological, interpersonal, social, occupational, and financial consequences [46]. Compulsive buying disorder was classified in the DSM-III-R as an impulse control disorder not elsewhere specified, but it was omitted from the DSM-5 [11; 300]. Since 2013, research demonstrates that compulsive buying disorder has several features that characterize addictions, including cue reactivity and cravings [289]. Although not recognized in the DSM-5 as a diagnostic entity, the following diagnostic criteria have been proposed for com- pulsive buying [85; 282; 284]: • Frequent, maladaptive preoccupation with, or engage- ment in, buying; intrusive, irresistible, “senseless” buying impulses • Clearly buying more than needed or can be afforded • Distress related to buying behavior • Significant interference with work or social functioning • The buying behavior does not occur exclusively during hypomanic or manic episodes The YBOCS-Shopping Version provides a robust, sensitive measure of compulsive buying disorder treatment response and can be used in the clinical screening of compulsive buy- ing disorder [301].
TREATMENT Psychological Interventions
Studies suggest that CBT, dialectical behavior therapy, and psychodynamic psychotherapy may have promising results in treating compulsive buying disorder [282; 302]. CBT focuses on identifying factors that maintain and reinforce the problem- atic buying behavior and delineates strategies for controlling
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