Abstract
Background
A
A number of diagnostic scales are available, with Compulsive Buying Scale by Faber and O’ Guinn being the one most commonly deployed in the United States.
It is most commonly found in developed Western countries with prevalence estimates from 1% to 10% of adult population. Women are generally overrepresented in samples. Individuals affected tend to be young in their early 20s (Black 2007).
Mueller et al. (2009) have found high rates of psychiatric comorbidities. These are commonly mood, anxiety, substance use, and personality disorders, besides other behavioral addictions.
Generally speaking, open-label trials of fluvoxamine (Black et al. 1997), citalopram (Aboujaoude et al. 2003), and naltrexone (Grant 2003) have generated positive results, but controlled trials failed to replicate these findings, hence, no empirically well-supported psychopharmacological recommendations can be drawn.
In this study, we are reporting on two interesting adolescent cases that developed “secondary” oniomania—one related to Methylphenidate (MPH) use in the context of attention-deficit/hyperactivity disorder (ADHD) and the other in relation to Aripiprazole (ARIP) use in borderline personality disorder (BPD).
Clinical Vignette (1)
A 14-year-old female Syrian youngster presented to our clinic for subpar scholastic achievement and reported mischievous behavioral facets. Weiss ADHD comorbid screen was administered, and a DSM-5 diagnosis of ADHD-combined presentation with oppositional defiant disorder was entertained. Wechsler (WISC-3) full-scale IQ read 89. No genetic load of psychiatric illness. She was started on MPH uptitrated to 30 mg/day (weight = 33 kg). Tangible improvements spanning academic, behavioral, and social domains were reported. However, 2 weeks later, she was noted to have episodes of overspending on accessories that she had to steal money from her father to afford it. This keeps escalating over 2 months' duration at frequency of thrice a week. This took its toll on parental stress. We reevaluated her; it was clear that these episodes had compelling, ego-dystonic nature, anxiety-packed experiences that typically end with self-loathing regret accompanied with dissociated effect (affective block). Probing of manic symptoms was unrevealing. Reduction of MPH down to 15 mg/day resulted in reduced frequency of these episodes once a week. A trial off-MPH was pursued and these episodes totally dissipated. Swapped to atomoxetine at 40 mg/day for 2 months had a mediocre response, if any, regarding her ADHD symptoms. To restore the therapeutic response, MPH was back to 30 mg/day. A week later, she started to indulge in these compulsive buying episodes over again. Add-on fluvoxamine up to 200 mg/day was introduced over 6 weeks. These episodes totally abated. Naranjo scale of six confirmed that these episodes are MPH related. Six months have elapsed at time of writing this report and she is in full remission regarding these episodes.
Discussion
Obsessive-compulsive and related disorder comorbidity in ADHD is quite ubiquitous given shared frontostriatal circuitry (Naguy and Al-Tajali 2015). Impulsivity is a core symptom of ADHD itself, which might manifest as oniomania. Stimulant-induced or exacerbated obsessive-compulsive disorder (OCD) has been reported (Naguy 2017). Paradoxically, stimulants have been used to address treatment-refractory OCD (Kellner 2010). Stimulant-induced mania (Akiskal bipolar III 1/2) has been described (Angst 2007). All these have to be factored in while working the differential of oniomania in the setting of ADHD. In our case, the temporal relationship and absence of bipolarity leaves us with the possibility of MPH-induced oniomania. This might be mechanistically due to boosting dopamine (DA) in the prefrontal cortex by MPH. This is akin to the so-called dopamine dysregulation syndrome in Parkinson's disease (Cilia et al. 2014). Fluvoxamine has similarly been used to address oniomania.
Clinical Vignette (2)
A 17-year-old female Iraqi youngster, a known case of DSM-5 BPD, was admitted to our inpatient facility in catathymic crisis and parasuicidality. She was put to ARIP 5 mg/day for affective dysregulation and interpersonal psychopathology and scheduled for dialectical behavioral therapy sessions and soon discharged. On follow-up, ARIP was pushed up to 10 mg/day for behavioral dyscontrol. Few weeks later, she disclosed repeated episodes of garment purchase with shopaholic behavior that she felt loss of control over it, endured with marked personal distress, and terminated by plunging into depressive crash. She had to borrow a big sum of money from her only friend to afford these irresistible bouts as she put it in her own verbatim. This occurred at a frequency of twice weekly for a whole month. Screening for bona fide bipolar disorder had negative yield. Toxic screen was negative. Electroencephalogram (EEG) was done and revealed nonspecific epileptiform discharges. ARIP was halted (no tapering). After 3 weeks, these episodes came to end. A rechallenge with ARIP was pursued up to 10 mg/day. Likewise, she began to reexperience similar episodes but this time triggered by feeling bored as she described. This caused explosive reactions when family tried to stop her. ARIP was discontinued. She was then prescribed lamotrigine titrated up to 100 mg/day for her temper outbursts. Naranjo score of six confirmed that these episodes are ARIP induced. Six months have elapsed at time of writing this report and she is in full remission regarding these episodes.
Discussion
ARIP has a sound evidence base for use in BPD cutting across all domains of borderline psychopathology, including impulsivity. Paradoxically, ARIP has been reported to disinhibit impulses (Kodama and Hamamura 2010). FDA in 2016 has warned about it. Oniomania might be reflective of borderline impulsivity. It might be a concomitant of bipolarity that might confound borderline presentations. It can also be triggered by substance use disorder, which is invariably commonplace in cluster B personality disorders. Over again, all these need to be factored in while working the differential of oniomania in BPD. In our case, these were all ruled out leaving us with the possibility of ARIP-induced oniomania. This might be ascribed to partial dopaminergic activity at D2/D3 receptors.
Conclusion
Oniomania, or CBD, an acquisitive impulse dyscontrol disorder, is not officially acknowledged in current classificatory systems, but remains a valid diagnostic construct on clinical grounds. Clinicians should be vigilant and mindful for cases arising de novo in the context of using psychotropic agents boosting DA tone. It behooves clinicians to work through the differential in Table 1 before the diagnosis of stand-alone oniomania.
ARIP, aripiprazole; OCD, obsessive-compulsive disorder; OCRDs, obsessive-compulsive and related disorders.
Footnotes
Acknowledgments
Authors extend their deepest gratitude to Dr. Naif Al-Harby, Director General of KCMH, and Dr. Abdul-Mohsen Al-Humoud, FRCPC, Consultant Adult and Forensic Psychiatrist and Head of Psychiatric Departments, KCMH, for their valuable scientific input.
Disclosures
No competing financial interests exist.