Abusing Chocolate and Bipolar Diagnoses

Is chocolate a legal "social drug" of abuse in the same category as nicotine, caffeine, and alcohol? Do you hang out at chocolate cafes with the purpose of becoming high or intoxicated? No? Have you heard of cancer-related deaths due to chocolate or driving under the influence of chocolate?

And really, how much chocolate is considered "chocolate abuse"?¹

A new paper by Maremmani et al. (2011) addressed none of these questions, but asked 562 depressed Italian outpatients about their cigarette, coffee, and chocolate consumption. Why? Actually, it's not clear.

Across all ages and cultures, mankind has always used substances in order to induce pleasurable sensations or desirable psychophysiological states. These substances, notably caffeine, tobacco, alcohol and chocolate, given their widely accepted recreational use, can be labeled ‘social drugs’.

This passage appeared as Background in the Abstract and as the first two sentences of the Introduction: brief literature review. But we have no explanation of why cigarettes, coffee, and chocolate are assumed to be "social drugs". Are there no solitary smokers, drinkers, and eaters? Look at the large number of singletons staring at laptop screens at any Starbucks. However, cafe culture in Italy or France does allow for smoking, espresso sipping, and chocolate croissant nibbling all at the same time. Also, anti-smoking laws in other countries force smokers to congregate outside to smoke, which often turns into a social activity.

But why look at the consumption of "social drugs" in people who are depressed? Aren't these individuals less inclined to be social? And aren't they likely to show anhedonia (loss of interest of pleasure) according to DSM IV criteria?

2) markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation made by others)

We're reminded that caffeine improves mood and cognitive performance, increases mental energy, and reduces fatigue, that nicotine increases attention and working memory, and that chocolate can also improve mood and even reduce stress. We're also reminded that psychiatric patients use more drugs than those in the general population:

With regard to caffeine, in hospitalized psychiatric patients the prevalence of tolerance and intoxication is significantly higher than in the healthy population. The highest caffeine intake has been found in patients suffering from eating disorders (Ciapparelli et al., 2010) and schizophrenia (Rihs et al., 1996), the lowest in patients with anxiety disorders and major depression (Ciapparelli et al., 2010; Rihs et al., 1996).

It's well known that the prevalence of smoking among individuals with schizophrenia is quite high (70-80%), higher than for those with other mental illnesses (Winterer, 2010). In fact, smoking is often considered a form of self-medication. So are cigarettes a "social drug" for smokers with schizophrenia?

Finally, we have the case of chocolate, where Maremmani et al. (2011) issue a number of curious pronouncements:

Lastly, the consumption of chocolate has shown interesting forms of linkage with psychiatric conditions. The correlation most often studied is that with depression: it has been observed that the craving for the rewards given by chocolate intensifies when depressive mood is induced... More severe depressive symptoms have been associated with higher chocolate consumption (Rose et al., 2010). Self-labeled ‘chocolate addicts’ do not generally seem to suffer from eating disorders, but may constitute a population of psychologically vulnerable people with a high predisposition to depression and anxiety disorders (Dallard et al., 2001). More specifically, a craving for chocolate seems to be unusually high not only in cases of depressed mood, but also in conditions of emotional dysregulation, like anxious and irritable states. The capacity to find comfort in eating chocolate seems to be related to the biological mechanisms of emotional instability,² so that the depression associated with a craving for chocolate turns out to be an efficient discriminator of hysteroid dysphoria³ and DSM-IV atypical depression (Parker and Crawford, 2007; Schuman et al., 1987).

So of the three "social drugs", chocolate seems like the winner among depressives of any sort, especially those with the greatest emotional dysregulation (i.e., those with bipolar disorder).

Then the introductory narrative inserts a non sequitur or three on illegal drugs of abuse (heroin and cocaine) and alcohol use in bipolar disorder, and "cyclothymic traits" in bipolar individuals, heroin addicts, and alcoholics. Furthermore........

This reported bipolar connection, in our opinion, is not just valid at a clinical level. We have stressed the possible role of the bipolar spectrum in the pathogenesis of substance use disorders. In particular, our integrated model provides an explanation for why the bipolar spectrum is the psychic substrate for the development of a substance-resorting attitude...

So let's blur the lines between alcoholics and coffee drinkers, schizophrenic smokers and chocolate-craving dysthymics, severe bipolar I disorder and mild cyclothymia, shall we? Then what?

The 562 depressed Italian outpatients were initially given one of four DSM-IV-TR diagnoses:

192 patients with a Major Depressive Episode, 212 with Major Depression, Recurrent, 119 with Bipolar Depression, and 39 with Depression NOS (“not otherwise specified”).

The participants also filled out the Hypomania Checklist (HCL-32) and according to the dichotomous rating procedure, there were 306 non-bipolar and 256 bipolar depressive patients [vs. 119 bipolar depressives according to DSM-IV-TR]. This illustrates the expansionism of the "bipolar spectrum" project, which is a major goal of the senior author.

Then we have the vague quantification of chocolate use:

The social drug habit was recorded in terms of the use of tobacco, coffee and dark chocolate-based food (chocolate bars, hot chocolate, chocolate-containing ice cream, biscuits or cakes). We classified smoking habits by division into 3 ascending ranks: total non-smokers, past regular users and current regular users and considered one cigarette as a “unit”. As to coffee, we distinguished between regular consumption (at least one coffee a day) and sporadic or no use [one cup was considered a unit].

What was considered a chocolate "unit"? The paper doesn't say.

To reiterate: the goals of the study were to prove that the notion of "bipolar" should be expanded, and that those on the "bipolar spectrum" are more likely to abuse substances of any sort.

And did the results support these ideas? Well, 44.5% of the DSM-IV-TR bipolar depressives were current smokers, and 43.4% of the HCL-32 bipolar depressives were current smokers. However, the statistics were only significant in the latter case, because the comparison was between only two groups, instead of between four groups. Even better are the number of cigarettes smoked daily: 10.66 for the DSM bipolars [vs. 8.13 for the other groups combined], and 10.45 for the HCL bipolars [vs. 7.51 for the non-bipolars]. The stats were nonsignificant in the first case (p=.33) and highly significant in the second case (p=.0003).

In contrast, there were no differences in chocolate consumption no matter how you divided the groups, which did not seem to disturb the authors. After touting the psychotropic properties of chocolate in the Introduction, they concluded:

It should be noted at this point that the result for chocolate should not necessarily be regarded as contradictory with the findings for coffee and cigarette use; the fact is that regular chocolate eaters appear to crave for chocolate to enjoy its taste, without paying any special attention to its potential psychotropic properties...

Time for a box of Ghost Chili Salted Caramels!

Footnotes

¹ "I'd go with a pound a day and you've got a problem."

² So we all know a lot of unstable people, then...

³ Which is not the same as PMS, of course...


References

Maremmani I, Perugi G, Rovai L, Maremmani AG, Pacini M, Canonico PL, Carbonato P, Mencacci C, Muscettola G, Pani L, Torta R, Vampini C, & Akiskal HS (2011). Are "social drugs" (tobacco, coffee and chocolate) related to the bipolar spectrum? Journal of affective disorders PMID: 21605911

Winterer G. (2010). Why do patients with schizophrenia smoke? Curr Opin Psychiatry 23:112-9.