--Janice Papolos and Demitri F. Papolos, M.D.
One of the
questions we asked on the initial survey for The Bipolar
Child, concerned a craving for carbohydrates: did the child
or adolescent crave starchy foods such as potatoes, breads,
pastas, and macaroni and cheese? or sugary foods such as candy,
cookies, and ice cream? We'll never forget the follow-up phone
interview we had with a young woman who had indicated a craving
for carbohydrates all through her childhood and into the present.
As we asked her to describe the cravings, there was a giggle
at the other end of the phone. She asked: "Would you consider
a gallon of Breyer's chocolate chip mint every night a craving?"
She went
on to tell us that her craving was so strong that she would buy
half a gallon and eat it in the car and then go back to the store
and buy another one. We asked if she kept a supply of plastic
spoons in her car. She laughed out loud and said: "No, I
would use my fingers. It was savage."
Adolescents
have recounted pouring sugar straight out of the box down their
throats; and mothers have told us that long ago they nicknamed their
children "Carb King" or "Spud." We recently
interviewed "Spud," but first we asked her mother to describe
her daughter's tremendous intensity about eating potatoes. "What
if she doesn't get them?" we asked. "It gets really, really ugly," she replied quietly. When we asked her what
"ugly" meant, she said: "See what Katie will tell
you. Katie will be totally honest about it."
We reached
Katie on the phone and she explained:
Say I'm doing my homework, and suddenly I get a craving for potatoes. I shut down and can think of nothing else. I get into "mission mode" and start to worry: What will I do if I can't get them? I will be totally lost. Where can I go from here? I won't be able to get off this.
If my mother
says: "I don't have potatoes, Katie, and I'm not going out in
this weather to get them," I get really, really angry. Most of
the times we have a huge screaming match, but sometimes I push
her because I am so mad. I see my mother as my enemy because she's
not supplying me with what I need. She is a total obstacle to
what I need. The word "no" is evil. It is not acceptable.
She also said that after she storms off, she comes back 15 minutes later and apologizes because she can't believe she acted that way over a potato.
Katie isn't
the only one who craves potatoes. The mother of a nine-year-old
boy wrote to us and said:
As
far as the carbs, he is a bread and mashed potato child. I almost
force-feed him anything else. He would eat huge piles of mashed
potatoes if I let him. He loves and gets obsessive about eating
them, and during the mornings and evenings he is just ravenous and
I almost have to follow him around to keep him from eating everything
in sight - mostly bread, chips, and stuff. I don't keep a lot of
sweets around for that reason.
Many parents
report that their children are extremely finicky about the foods
they eat, and some eat only white foods (bread, pasta, French fries,
potatoes, and rice); or eat an equally narrow repertoire of food
that consists of four or five items with a preference (or aversion)
for certain textures. Some crave one kind of food to the exclusion
of all others, and then, after a month or so, seem to lose all interest
in eating it.
Parents watching
their children's weight ballooning as the kids maraud through the
kitchen day after day, night after night, wonder anxiously (and
often with some level of disgust) what they can do to stop these
gorging, out-of-control behaviors.
What
Is Going On?
While it has
long been known that adults who suffer Seasonal Affective Disorder
(SAD) have a marked craving for carbohydrates in the winter months
and are not as ravenous about starchy or sweet foods in the spring
and summer months, there are no published studies about children
and this phenomenon. However, when the researchers of the Juvenile
Bipolar Research Foundation looked at a sample of over a thousand
children at risk for, or diagnosed with bipolar disorder, over 65%
of the parents endorsed the item "craves sweet-tasting food
or carbohydrates" at a frequency rate of "often,"
or "very often or almost constantly." In other words,
it wasn't always seasonal.
This
would fit with the poor regulation of drives - particularly appetitive and acquisitive drives - seen so often in the childhood
form of the disorder. Natural drives become obsessive and overwhelming
and difficult to modulate. Although survival of the human species
has depended on a sometimes hell-bent foraging and storing of food,
this is natural instinct writ large and inappropriate for life today
when supermarkets are often a block or two away, and refrigerators
and cabinets typically boast an abundance of food.
The
Biological Basis
The appetitive
craving for carbohydrates is modulated by a complex cascade of neuropeptides,
hormones, and the receptors through which they act and are acted
upon in various feed back loops. One of these peptides, Neuropeptide
Y (NPY), is thought to play a major role in the craving for carbohydrates.
Neuropeptide
Y is produced by a dense cluster of cells inside the hypothalamus
at the base of the brain known as the paraventicular nucleus.
NPY is the most abundant behaviorally active neuropeptide in the
brain. Studies show that injections of NPY into the ventricles of
the brain, cause an animal to forage and to consume carbohydrates
to the exclusion of all other foods.
Among the
actions of central NPY, the peptide exerts an influence on neuroendocrine
systems that regulate appetite, circadian rhythms, and. through
effects on the hypothalamic-pituitary-adrenal (HPA) axis, the stress
response that regulates the output of corticosteroids that, in turn,
influence carbohydrate metabolism. Typical symptoms and abnormal
behaviors that represent a dysregulation of appetite are carbohydrate
cravings, binge eating, hoarding, bulimia, and anorexia-all commonly
associated with mood disorders. Though tempting to anticipate, there
is little direct evidence of altered functioning of NPY in such
behaviors. Moreover, there are no clinical treatments yet that directly
alter NPY functions.
The
Sense of Deprivation
Remember Katie's
telling us that she found her mother's "no" to her need
for potatoes "unacceptable," and that she saw her mother
as an obstacle getting in the way of what she needed?
Katie's mother's
"no," or her inability to meet Katie's needs at that moment
in time, catapulted her into a rage?
Children and
adolescents with bipolar disorder appear to have a low threshold
for anxiety and are over-reactive to stressful events (real or perceived)
such as deprivation, loss, rejection, and humiliation. (This may
be why these children so over-react to the simple word "No,"
which in its expression contains elements of deprivation, loss,
rejection, and humiliation.)
Something
else stands out in Katie's comments: her worry that she would be
lost if she didn't get what she needed and couldn't get past her
fixation on the food: "What will I do if I can't get them?
I will be totally lost. Where can I go from here? I won't be able
to get off this."
Children and
adolescents with bipolar disorder often have rigid and inflexible
thinking. They get stuck, and they have difficulty estimating time
and cause-and-effect, and become "prisoners of the present."
Katie's anxiety about being trapped in time and space without access
to the potatoes that are the source of her intense cravings, arouses
irritability, and great fear as well as anger.
Hoarding
and Hiding
A craving
for carbohydrates leads to a number of behaviors that are manifestations
of the appetite dysregulation that may help to define one aspect
of the core syndrome of bipolar disorder in childhood. Those behaviors
include foraging (going after and finding the food), binging and
hoarding.
In the animal
world, foraging and hoarding (provisioning for winter or famine)
are necessary for survival. But many parents report dismay when
they discover these hoarding behaviors when they simply move the
beds in their kids' rooms. The space behind or to the side of the
beds reveal caches of candy bars, potato chips, soda cans, and cookies.
Empty wrappers are strewn around these "nests." The kids
may be hoarding for a time when they may need immediate access to
carbohydrates. It is part of the acquisitive drive and the appetitive
dysregulation.
Katie hoards,
and she doesn't hide her need behind the bed. She concocts this
potato casserole (potatoes, cheese, and sour cream), and has to
know that half of it is in the refrigerator in case she has a sudden
craving. She guards this casserole aggressively. When we asked her
what would happen if her younger brother decided to have a late-night
snack of potato casserole, she laughed and said: "That would
never happen. He is afraid of the wrath of Katie!"
Medication-induced
Cravings
Not only do
many of the children with bipolar disorder gain weight from constant
binging, but, unfortunately, some mood stabilizing drugs and atypical
antipsychotics can cause weight-gain (sometimes in alarming amounts
and extraordinarily rapidly). Moreover, children seem to be even
more sensitive than adults to the weight-gain effects of antipsychotic
and other psychotropic drugs.
Some of the
medications used to treat bipolar children cause an extreme, insatiable
hunger. The mother of a boy on a commonly-prescribed mood stabilizer
made a list of the fantastic amounts of food her son was eating
in the first few weeks on the medication. In a few hours he consumed:
five packets of instant oatmeal with tons of sugar on top, four
potatoes, two cheeseburgers, two pieces of chicken, one hamburger
bun, one piece of coffee cake, sixteen ounces of grape juice, and
twenty ounces of Mountain Dew.
Some of the
modern antipsychotic drugs, including olanzapine (Zyprexa), quetiapine
(Seroquel) and clozapine (Clozaril, and generics), can be particular
offenders for many children. We have heard of children gaining two
pounds a day with certain of the atypical antipsychotic drugs. While
it is not understood completely, one theory postulates that the
degree of weight gain is correlated with the drug's affinity for
histamine (H-1) receptors. Olanzapine and clozapine and quetiapine
have greater affinity for H-1 receptors than do risperidone (Risperdal)
or aripiprazole (Abilify). These drugs also seem to have synergistic
effects on the H-1 receptors, as well as certain serotonergic receptors
implicated in regulating appetite.
The hunger
and weight gain do not happen to all children, but should be anticipated.
Low-calorie snacks and drinks as well as an increased daily exercise
schedule should be planned. Ideally, the child should be seeing
a nutritionist who can explain all of this in a calm matter. Some
physicians add the anticonvulsant topiramate (Topamax) to the medication
mix in moderate doses, as this drug has appetite suppressant effects.
However, its status as an effective mood-stabilizer remains uncertain,
and it is not FDA-approved for that purpose. Other newer anticonvulsants,
including zonisamide (Zonegran), may have similar appetite-reducing
effects, again with uncertain effects on mood and behavior.
Light
therapy in adults seems to have an effect on carbohydrate craving,
but no studies of this phenomenon have been reported in the young.
Life
in the Fast-Food Nation
Parents of
bipolar children have the deck stacked against them in this country.
Carbohydrate-dense fast food is so available on every street corner,
as well as in the school cafeteria, that urges can be satisfied
easily. Rapid increases in serum glucose levels result in subsequent
rapid decreases, and this drop jump-starts intense carbohydrate
cravings. Cycles of craving and binging, are easily set off in children
who are already biologically primed for these cycles.
And these
cycles, unfortunately, promote mood swings - even in people who
don't have the disorder.
In director
Morgan Spurlock's fascinating documentary film, Supersize Me,
he limited his diet to three meals a day of McDonald's carbohydrate-dense
food, intending to play out this experiment for a month.
Within days
he was waking up feeling terrible, and, besides gaining 32 pounds
over several weeks and almost destroying his liver, he suffered
intense mood swings from the rapid doses of carbohydrates into his
body, and the subsequent drop in glucose levels. "I feel sick
and unhappy," he revealed mid-project, "and then I eat
and feel really, really good. So good, I feel crazy."
Referring
to his cravings, the doctor monitoring the experiment told him:
"You're craving these foods; they have become a drug for you."
The pursuit
of carbohydrate-dense food that many of the children experience
is so difficult for parents to combat - and not just because of
Neuropeptide Y and other chemical cascades.
Mr. Spurlock's documentary points
out that the average child in America sees 10,000 television commercials a year
advertising sugary cereals, soft drinks, fast foods, or candy. By the time children
can speak most of them can say "McDonald's."
When the director
assembled a group of teenagers and adults (with the White House
as a backdrop), they stumbled through the Pledge of Allegiance,
but they could quickly recite the theme tag of McDonald's and other
fast-food establishments. Children in America are subliminally primed
to crave junk food, and this reinforces the innate longing for fixes
of carbohydrate-dense foods in children and adolescents with bipolar
disorder.
So
What's A Parent to Do?
A friend of ours with a fifteen-year-old teenager who had early-onset bipolar disorder put her ideas into an e-mail. She wrote:
We've been
battling the carbohydrate-addiction problem for years. We see
his urgent need to eat certain foods, and we wonder if the meds
are pumping up his appetite or the disorder itself is causing
the compulsion to eat. We see the same "mission mode"
around foods that we see in so many other areas of his life. In
fact, our parenting sometimes feels like 24-hour mission control.
The food
thing, though, seems most important because obesity is such a
health risk and can do so much to damage self-esteem. I don't
think there's a perfect solution, but there are a few little strategies
that we've found helpful.
One is to
limit - not eliminate - availability of binge-provoking foods.
For example, Jeremy loves these certain cereal bars. They're not
bad things to eat, it's just that he can't eat just one or even
two. I don't want to have a situation where the rest of the family
can't have anything in the house because we're trying to keep
Jeremy from eating. So I still buy the things that are enjoyed.
But I put most of them away in a cabinet in the garage where he'll
never look. I take a few items from the box and put them in the
kitchen pantry, one per day per kid. That way I can keep my eye
on the quantity consumed without totally depriving.
It's like
bird-feeding. You put a little seed out on the platform, and when
it's gone you replenish it.
Jeremy's mother (and Katie seconded this) feels that a small meal before dinner is helpful. Jeremy's mother said:
I require
him to eat a fruit or a vegetable or a salad before he starts
the main meal. That way he fills up a little before digging in
to the meat and potatoes. I know people who try to cut out the
carbs, and believe me, it doesn't work. It leaves him feeling
too unsatisfied and angry.
After the
meal, we sometimes impose a waiting period before any dessert.
Sometimes he gets involved with the computer and forgets all about
it for quite a while.
Despite all
these steps, he's still overweight to one degree or another. There
are seasonal ups and downs. He loses in the summer and gains toward
the winter, like a bear before hibernation. He can't regulate
his cravings, and our job is to be his regulators. But really,
you can only control so much.
She closed
by saying:
Bottom line,
I think we have to be realistic and not rigid. Sometimes I think
it's okay for our parenting to have more give. Winter is not the
time to crack down. In the summer there are more opportunities
for constant exercise and for distractions from the obsession.
It's important
that we all keep our sanity - right?
In
Conclusion
When we spoke
to Katie in a follow-up phone call, we briefly mentioned a few of
the biological factors that might be at play concerning her overwhelming
need for carbohydrates. She liked the idea that there was something
called Neuropeptide Y, and that the cravings didn't necessarily
mean she was willful or horrid, or that she was necessarily trapped
and couldn't find a better way to resolve the problem.
Her mother
also seemed to relax after she read this newsletter, and gained
some sympathy for Katie's problem. She thinks she can be less angry
and more tolerant of Katie's irrational demands, which are, after
all, not of her own choosing.
We'll write
again soon. Meantime, at this time of mid-winter and always, we
wish you and your children the best,
Janice Papolos and Demitri
Papolos, M.D.
The authors
wish to thank Cheryl Matalene, Heidi Rochon, and our absolutely
charming Katie for their astute discussion of this problem. A special
thank you to Ross J. Baldessarini, M.D. who stands at our side with
such wisdom.
References
Allison DB,
Mentore JL, Heo M, Chandler LP, Cappelleri, JC, Infante MC, Weiden
PJ. "Antipsychotic-induced weight-gain: A comprehensive research
synthesis." American Journal of Psychiatry 1999; 156: 1686-1696.
Allison DB,
Mentore JL, Heo M, et al.: "Antipsychotic-induced weight-gain:
A comprehensive research synthesis." American Journal of Psychiatry
1999; 156: 1686-1696.
Berman K,
Lam RW, Goldner EM. Eating attitudes in seasonal affective disorder
and bulimia nervosa. Journal of Affective Disorders. 1993; 29: 219-225.
Christensen
L.: The effect of carbohydrates on affect. Nutrition. 1997;13: 503-514.
Ishi T, and
Elmquist, JK. Body weight is regulated by the brain: a link between
feeding and emotion. Molecular Psychiaty,2005: 10:1-15.
"Katie."
Telephone Interview of January 15, 2005.
Matalene,
C. E-mail of January 18, 2005.
McIntyre,
R., DA Mancini, and V S. Basile. "Mechanisms of antipsychotic-induced
weight-gain." Journal of Clinical Psychiatry 2001; 62 (Suppl
27): 23-29.
Meyer, JM.
"Effects of atypical antipsychotics on weight and serum lipid
levels." Journal
of Clinical Psychiatry 2001; 62 (Suppl 27): 27-34.
Neuropsychopharmacology:
The Fifth Geenration of Progress. Edited by Davis KL, Charney D,
Coyle JT, and Nemeroff C.Philadelphia: Lipponcott and Wilkins. 2002.
Oommen KJ,
Mathews S. Zonisamide: a new antiepileptic drug. Clinical Neuropharmacology
1999;22: 192-200.
Papolos, D
and J. The Bipolar Child, Revised. New York: Broadway Books, 2002.
Rochon, H.
E-mail of January 13, 2005.
ADDITIONAL NEWS:
(New on the JBRF Web site)
For those of
you who have been asking about the new DVD, Educating and Nurturing
the Bipolar Child by Janice Papolos, it is available on the Web
site of the Juvenile
Bipolar Research Foundation.
This DVD is
a compassionate look at what a student with bipolar disorder faces
minute-to-minute throughout the school day.
It reveals
to the viewer the often unrecognized, and insidious factors that
severely impact the children in the academic environment, causing
them such frustration and such a sense of failure, in school and
at home. These include:
- Executive
function deficits
- Severe anxiety
- Poor working
memory
- Difficulty
with the concept of time
- Difficulty
with tasks requiring sequencing
- Disorders
of written expression
- Reduced
alertness in the morning (sleep inertia)
The presentation
is less than an hour long, and it gives teachers and parents easy-to-implement
strategies and tools that make learning less stressful and more
fulfilling.
Each DVD is $20.00, and all proceeds support JBRF research projects.
To order a
copy of Educating and Nurturing the Bipolar Child, please click
here or visit the Web site of the Juvenile Bipolar Research
Foundation. (http://www.jbrf.org)
