________________________________________________________________________ Behavioral Addictions
impulsive spending. Maintaining a diary to identify triggers, describe the shopping behavior itself, and record the conse- quences of compulsive shopping assists patients in understand- ing behaviors from a different perspective. Additional options include 12-step programs such as Debtors Anonymous, debt consolidation, and credit counseling [282; 303]. Group Psychotherapy Group psychotherapy that uses a CBT approach or cognitive- behavioral methods within an eclectic approach appears beneficial, with durable improvements in reducing distress associated with compulsive buying disorder and maladap- tive buying behavior. Research suggests that impulse control training should be a core component of compulsive buying disorder treatment [289]. Attrition rates show that group psy- chotherapy is not acceptable to all patients with compulsive buying disorder; patient choice and suitability are important considerations [289]. Stepped Care Delivery Model Evidence suggests that a low-intensity, guided self-help approach to treating compulsive buying disorder was com- parable to high-intensity group therapy. If patients can be treated with effective, brief, and less intensive psychological interventions first, this may increase service throughput and efficiency [304]. Studies of Internet-based, therapist-assisted self-help programs also usefully mimic the shift of behavior in online shopping [305]. Research indicates that excitability regarding online shopping and compulsive buying disorder are mediated by Internet use expectancies [294]. Treatments clearly need to reflect the context within which compulsive buying occurs [289]. Effect of Reward and Punishment Sensitivity on Treatment Response Reward and punishment sensitivity was studied for impact on treatment outcome (12 weekly CBT sessions) in female patients with compulsive buying disorder or gambling disorder [46]. In compulsive buying disorder, higher reward sensitivity was related to poorer treatment adherence but reduced risk of dropout. Patients were likely to have stronger intrusive urges to buy, interfering with ability to curb buying behavior and carry out practice homework for CBT. The lower dropout risk may reflect patient motivation by social factors, with patients more likely to form a therapeutic alliance and not abandon treat- ment. High punishment sensitivity correlated with harm avoid- ance; these patients had increased risk of treatment drop-out. Among all patients, high reward and punishment sensitiv- ity was associated with greater psychopathology; worse psychological adjustment and treatment outcomes; higher novelty-seeking, persistence, and self-transcendence; and low self-directedness and cooperativeness. These results suggest patient response to CBT is conditioned by sensitivity to reward and punishment; compulsive buying disorder and gambling
disorder shared this phenotype. This information could be incorporated into targeted interventions to strengthen CBT efficacy in compulsive buying disorder [46]. Pharmacologic Interventions A review of compulsive buying disorder treatment found few published pharmacotherapy studies. SSRI antidepressants are the most-studied pharmacotherapy, based on the same premise as their use in other behavioral addictions [85]. Evaluations of citalopram, escitalopram, and fluvoxamine have reported mostly negative results, and clinicians should consider psy- chotherapeutic options before pharmacotherapy [289]. A systematic review of treatment studies found that group CBT is effective in reducing symptoms of compulsive buying disorder, whereas pharmacotherapy with SSRIs or topiramate did not indicate superiority over placebo [306]. One literature review found that a combination of antidepressants and CBT is effective for management of compulsive buying disorder. Sero- toninergic antidepressants are effective as monotherapy [302]. TRICHOTILLOMANIA (HAIR PULLING DISORDER) Trichotillomania is the repetitive pulling out of one’s own hair, leading to hair loss and functional impairment. Although documented in the medical literature since the 19th century, trichotillomania has received little research attention [307]. In clinical settings, the preferred term for this condition is ‘‘hair pulling disorder’’ [308]. EPIDEMIOLOGY Community prevalence studies suggest that trichotillomania occurs in 0.5% to 2.0% of the population [309; 310]. Lifetime prevalence is estimated to be 1% to 3% [311]. In adults, tricho- tillomania predominately affects women (4:1 female to male), but childhood trichotillomania shows equal sex distribution [309; 310]. As a behavior, hair pulling appears quite common and often presents along a continuum from mild to severe. When hair pulling meets the criteria for trichotillomania, interventions should be considered [312]. CLINICAL FEATURES The typical age of onset for trichotillomania is consistently found to be 10 to 13 years of age. The natural history may vary, but untreated trichotillomania is usually a chronic disorder with fluctuating intensity; studies show an average illness duration of 22 years. Symptom intensity usually waxes and wanes, but persists without treatment [312; 313]. With hair pulling in trichotillomania, the scalp is the most common site (72.8% of patients) followed by the eyebrows (56.4%) and the pubic region (50.7%) [312]. Triggers to pull can be sensory (e.g., physical sensations on the scalp, hair thickness, length, and location), emotional (e.g., feeling anx-
61
EliteLearning.com/Social-Work
Powered by FlippingBook