One-third of patients with buying-shopping disorder (BSD) reported an addiction to online shopping

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A new study in Comprehensive Psychiatry found that one third of a group of patients seeking treatment for buying-shopping disorder (BSD) also reported symptoms of addictive online shopping.

These patients tended to be younger than the others in the study sample, experienced greater levels of anxiety and depression, and were likely to exhibit a higher severity of BSD symptoms.

“It really is time to recognize BSD as separate mental health condition and to accumulate further knowledge about BSD on the Internet,” explained lead investigator Astrid Müller, MD, PhD, Department of Psychosomatic Medicine and Psychotherapy, Hannover Medical School, Hannover, Germany.

At present, BSD is not categorized as a separate mental health condition; it is characterized as “other specified impulse control disorder” in the recently released 11th revision of the International Classification of Diseases.

BSD is a cross-national problem that afflicts an estimated five percent of the population.

It is characterized by extreme preoccupation with and craving for buying and/or shopping, as well as irresistible and identity-seeking urges to possess consumer goods.

Patients with BSD buy more consumer goods than they can afford, need, or use.

Their excessive purchasing serves to regulate emotions, e.g., to get pleasure, relief from negative feelings or cope with self-discrepancy.

In the long run, the recurrent breakdown in self-control leads to extreme distress, psychiatric comorbidity, familial discord, clutter due to pathological hoarding of goods, and indebtedness and/or deception and embezzlement to enable continued spending despite insufficient finances.

Previous studies showed that certain Internet-specific aspects of buying and shopping, such as availability, anonymity, accessibility, and affordability, contribute to the development of an online subtype of BSD.

As e-commerce has gained increasing popularity as a primary method for buying and shopping for goods over the past decade, a need has developed for mental health experts to explore whether traditional BSD manifests differently in the online retail market.

The Internet offers a vast variety of shopping information and simultaneous access to many online stores, thereby meeting expectations for immediate reward, emotional enhancement, and identity gain.

Previous studies showed that certain Internet-specific aspects of buying and shopping, such as availability, anonymity, accessibility, and affordability, contribute to the development of an online subtype of BSD.

However, there is a paucity of studies investigating addictive online shopping as a phenotype of BSD related to the problematic use of the Internet.

This study, which analyzed data from earlier studies reporting on 122 treatment-seeking patients, is among the first to quantify and explore the phenomenon of online shopping in BSD diagnosed-patients.

Dr. Müller added, “We hope that our results showing that the prevalence of addictive online shopping among treatment-seeking patients with BSD will encourage future research addressing the distinct phenomenological characteristics, underlying features, associated comorbidity, and specific treatment concepts.”


Buying-shopping disorder (BSD) is characterized by extreme preoccupation with buying/shopping, an overwhelming urge to possess consumer goods, recurrent purchases of unnecessary things and irrational beliefs about material possessions [14].

According to patients’ reports, the excessive buying/shopping episodes generate a short-term reward (i.e. pleasure, fun, thrill, excitement, etc.).

With the progression of BSD, these episodes become habitual and serve to manage negative feelings (e.g. anxiety, depression, tension, frustration, boredom) and to escape distress [5,6].

Although the harmful spending behavior results in adverse consequences (e.g. debts, familial discord, clutter due to hoarded consumer items, comorbid mental disorders), repeated efforts to cut down buying/shopping activities remain unsuccessful [2].

In some cases, violations of the rights of others (e.g. deception, embezzlement) may occur in order to continue overspending despite indebtedness.

Population-based surveys of BSD have been carried out since more than 30 years [7,8].

They provided evidence that BSD is a public health problem across different cultures [913]. Results of a meta-analysis revealed a propensity towards BSD of about 5% in representative adult samples [14], which indicates the clinical need of any advance in basic research. BSD is associated with psychiatric comorbidity, including anxiety, depressive and hoarding disorder [1,3,15,16].

The release version of the 11th edition of the International Classification of Diseases (ICD-11) [17] does not include BSD as an independent mental health condition, but lists”compulsive buying-shopping disorder” as an example in the residual category”Other specified impulse control disorders” (category 6C7Y).

Impulse control disorders “…should be defined by the repeated failure to resist an impulse, drive, or urge to perform an act that is rewarding to the person (at least in the short-term), despite longer term harm either to the individual or others” according to the ICD-11 working group on obsessive-compulsive disorder and related disorders [18]. Phenomenologically, BSD seems to meet these impulse control disorder criteria [13].

However, recent research findings suggest that BSD should rather be considered a candidate for the proposed ICD-11 category”Other specified disorders due to addictive behaviors” [19,20]. Analogous to substance use disorders and gambling disorder, experimental studies emphasized the prominent role of cue-induced craving and reward processing, attentional bias, dysfunctional decision-making and deficits in response inhibition in BSD [2130].

Cue-reactivity and craving are acknowledged as underlying mechanisms in the development and maintenance of substance use disorders [31] and behavioral addictions [28].

According to the incentive sensitization theory of addiction, the frequent presentation of substance-related stimuli evokes an attentional bias and implicit (automatic) positive associations towards these stimuli due to classical conditioning, which results in cue-induced craving [32].

Similar to the repeated administration of a certain substance, recurrent activity in a rewarding behavior may strengthen the motivational properties, leading to subjective craving for this behavior.

As in substance use disorders, cue-induced craving for certain behaviors is supposed to be interrelated with an attentional bias and positive implicit cognitions towards behavior-related cues [3337].

With respect to BSD, it can be assumed that due to the immediate experience of gratification while buying/shopping, specific cues (e.g. shopping malls/websites, brands, commercials, price promotions) may become related to the positive reinforcing features of buying/shopping (“liking”), making these cues attractive. Subsequently, the confrontation with these cues may elicit strong craving for buying/shopping (“wanting”) [38] that is associated with positive cognitive responses and appetitive neural reactions towards the cues (i.e. higher activity in the ventral striatum) [21].

In other words, despite explicit negative cognitions towards BSD because of the long-term negative consequences (see above), the pathological consumer behavior may be maintained by an attentional bias and implicit positive cognitions towards buying/shopping stimuli.

Research using Dot-probe tasks has found an attentional bias towards specific addiction-related cues in individuals with substance use disorders [39,40], gambling disorder [33], and Internet-gaming disorder [34].

Implicit associations towards addiction-related cues have been frequently measured with the Implicit Association Test [41], e.g. in individuals with gambling disorder [35], Internet-gaming disorder [36], Internet-pornography-use disorder [37] and in children and adolescents with Internet-use disorder [42].

Besides the cognitive processes described above, a person’s ability to withhold or stop a behavior is crucial in the development and maintenance of addictions [43].

Inhibitory control abilities have often been measured using Go/no-go tasks in which participants have to react or inhibit responses to addiction-related vs. neutral cues [44].

Deficits in inhibitory control have been demonstrated in patients with substance use disorders [4547] and patients with gambling disorder [48]. Nicolai et al. [29] investigated inhibitory control abilities in relation to BSD in a convenience sample.

They found that those individuals who exhibited more symptoms of BSD showed impaired performance in the Go/no-go task. The association between symptom severity of BSD and impaired inhibitory control was stronger in negative mood states [29].

In view of the proposed interplay of cognitive processes, the dual-process models framework in human decision-making has been related to BSD [38].

Dual-process models consider two neural systems: a fast, impulsive, intuitive system (subcortically located, rather automatic; reacting to immediate reward and punishment) and a slower, reflective system that consciously works through different considerations (prefrontally located, rather controlled; linked to conscious deliberations) [49].

Addictive behaviors may occur because the impulsive neural system is not down-regulated by the reflective neural system or overrides the reflective system due to drug-related neuroadaptations [50].

Referring to BSD, the confrontation with buying/shopping-related cues may predominantly stimulate the impulsive system (i.e. increase the decision for the short-term rewarding option of buying/shopping), while reflective processing is diminished (i.e. poor spending self-control) [38].

These assumptions are in line with other 2-factor models of BSD that refer to biologically driven conceptualizations of personality and temperament [5152]. According to past studies [5354], BSD is significantly related to 1) increased emotional reactivity (bottom-up regulation; i.e. increased behavioral inhibition/activation system reactivity) and 2) deficient effortful control (top down regulation; i.e. reduced self-control) (for review see [55]).

Taken together, patients with substance-related and addictive disorders are likely to show cue-induced craving, attentional bias, implicit positive cognitions and impaired inhibitory control related to cues associated with the respective addiction.

Although knowledge about these processes will contribute to a more comprehensive understanding of the etiology of BSD and its overlap with, and differences to, substance-related and addictive disorders, relatively little effort has been devoted thus far to exploring these mechanisms. To address this research gap, the current study investigated cognitive processes and inhibitory control in a clinical sample of patients with BSD compared to a healthy control group.

It was expected that patients with BSD would suffer from more severe symptoms of anxiety, depression and hoarding disorders than healthy control participants. In terms of cue-induced craving, attentional bias, implicit cognitive processes, and response inhibition, the following hypotheses were drawn based on the literature and the theoretical considerations above:

  1. Patients with BSD will show more craving reactions towards buying/shopping-related cues and higher baseline craving for buying/shopping than healthy control participants.
  2. In patients with BSD, the symptom severity of BSD will be related to craving reactions.
  3. Patients with BSD will exhibit a higher attentional bias towards buying/shopping-related cues than healthy control participants within a Dotprobe task.
  4. Patients with BSD will show more implicit associations to buying/shopping-related cues with positive emotions than healthy control participants within an Implicit Association Test.
  5. Patients with BSD will show greater response inhibition deficits than healthy control participants in response to buying/shopping-related cues within a Go/no-go task.
  6. Given the role of craving as a result of the conditioning process in addictions, the relationship between symptom severity of BSD and performance in the aforementioned experimental tasks will be moderated by craving reactions in patients with BSD.


Source:
Elsevier
Media Contacts:
Astrid Müller – Elsevier
Image Source:
The image is in the public domain.

Original Research: Open access
“Online shopping in treatment-seeking patients with buying-shopping disorder”. Astrid Müller, Sabine Steins-Loeber, Patrick Trotzke, Birte Vogel, Ekaterini Georgiadou, Martina de Zwaan.
Comprehensive Psychiatry doi:10.1016/j.comppsych.2019.152120.

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