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Compulsive buying treatment with topiramate, a case report.

Dear Editor, Compulsive buying is occasionally described in the psychiatric literature despite suggestions that it may be prevalent. Its etiology is unknown, though speculation has settled on developmental, neurobiological, and cultural influences. The disorder was first clinically described in early 20th century by Bleuler and Kraepelin, both of whom included compulsive buying disorder in their textbooks. In 1994, McElroy proposed the diagnostic criteria for compulsive buying, including repetitive buying acts and compulsive buying thoughts. Compulsive buying is defined by the presence of repetitive impulsive and excessive buying leading to personal and familial distress. It is frequent among depressed patients. In most cases, the behavior is associated with other impulse control or dependence disorders and a high level of impulsivity. There are no standard treatments. Psychopharmacologic treatment studies are being actively pursued, and group cognitive-behavioral models have been developed and are promising. The pilot data suggest that cognitive behavioral interventions could be effective in the treatment of compulsive buying disorder. Fluvoxamine and other SSRI have been investigated as therapeutic approaches to addictions, compulsive behaviors, as well as compulsive buying. We are presenting what is believed to be the first case report of a patient affected by compulsive buying who responded to topiramate. Topiramate is a powerful anticonvulsant that has recently been proposed also for the treatment of migraine, bipolar disorder and binge eating disorder. Topiramate is an orally active anticonvulsant whose mechanisms of action include potentiation of GABA to activate GABA-A receptors and antagonism of glutamate at specific receptors. Although the efficacy of topiramate has not been evaluated yet in the treatment of compulsive buying, previous reports suggest that this compound might be beneficial in a variety of psychiatric illnesses, including affective disorders, eating disorders, posttraumatic stress disorder and obsessive-compulsive disorder. Maria is a 37-year-old woman, Caucasian, non-smoker, reporting no previous history of substance abuse, gambling, mood or anxiety disorders, who was an outpatient receiving treatment at the Institute of Psychiatric HC-FMUSP. She was diagnosed with persistent compulsive buying disorder and depression in 2004, with no accompanying obsessive compulsive symptoms, that did not respond to a previous treatment with fluoxetine. She reported that 3 years earlier, she started shopping without control, mainly clothes, and the expenses were increasingly higher, the activity lasting at least 10 hours a day. She was submitted to semi-structured interviews, scoring 26 out 63 points at the Beck Depression Inventory (BDI). She refused psychotherapeutic intervention several times. The medication was changed to venlafaxine up to 225 mg/d. After three months, she kept presenting depressive symptoms, the BDI score was still high (24) and she threatened to discontinue the medication due to weight gain (5 kg). Adjunctive topiramate was added, an initial dose of 50 mg titrated up to 150 mg/d in one month. One month later excessive compulsive shopping subsided, and after three months of this pharmacological treatment, depression fully remitted. Later, venlafaxine was discontinued. She did not report any adverse effect due to topiramate and accepts well the medication at that moment. A variety of studies and case reports have recently raised the interest in topiramate in the treatment of addictive disorders such as alcoholism. This case report suggests that topiramate might be beneficial in patients suffering from compulsive buying, although controlled studies to confirm our findings are needed.