Caffeine - Induced Psychiatric Disorders

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Article 353 1 Clock Hour Caffeine - Induced Psychiatric Disorders

Francis M. Torres

Caffeine is a bitter, white crystalline xanthine al- inability to quit or to cut down their caffeine use. The kaloid that acts as a psychoactive stimulant drug and a mood altering effects of caffeine depend on the mild diuretic1. In humans, caffeine is a central ner- amount of caffeine consumed and whether the indi- vous system (CNS) stimulant2, having the effect of vidual is physically dependent on or tolerant to caf- temporarily warding off drowsiness and restoring feine. In caffeine non-users or intermittent users, low alertness. Beverages containing caffeine, such as cof- dietary doses of caffeine (20-200 mg) generally pro- fee, tea, soft drinks and energy drinks, enjoy great duce positive mood effects such as increased well- popularity. Caffeine is the world’s most widely con- being, happiness, energetic arousal, alertness, and so- sumed psychoactive substance, estimated at 120,000 ciability. Among daily caffeine consumers, much of tonnes per annum3, but unlike many other psychoac- the positive mood effect experienced with consump- tive substances, it is legal and unregulated in nearly tion of caffeine in the morning after overnight absti- all jurisdictions. The half-life of caffeine — the time nence is due to suppression of low grade withdrawal required for the body to eliminate one-half of the total symptoms such as sleepiness and lethargy. Large caf- amount of caffeine — varies widely among individu- feine doses (200 mg or greater) may produce negative als according to such factors as age, liver function, mood effects. Although generally mild and brief, these pregnancy, some concurrent medications, and the effects include increased anxiety, nervousness, jitteri- level of enzymes in the liver needed for caffeine me- ness, and upset stomach. However, individual differ- tabolism. In healthy adults, caffeine’s half-life is ap- ences in sensitivity and tolerance affect the severity proximately 3-4 hours. The average daily consump- and likelihood of experiencing negative effects. tion of caffeine among Americans is 219 mg.4 Adults It is clear that caffeine is a drug reinforcer, mean- receive nearly three quarters of their daily caffeine ing the ability to sustain regular self-administration from coffee. Children receive one half of their caf- (i.e., drug-taking). People continue to use caffeine de- feine from soft drinks. Energy drinks represent a fast- spite having medical or psychological problems made growing beverage market. A combination of caffeine worse by caffeine in order to avoid experiencing and herbal ingredients are touted as providing an en- caffeine withdrawal symptoms. Withdrawal symp- ergy boost. Energy drinks vary in the amount of caf- toms — possibly including headache, irritability, an feine included in their formulations and can range inability to concentrate, drowsiness, insomnia and from around 50-300 mg. Consumers seeking the acti- pain in the stomach, upper body, and joints5— may vating qualities of caffeine in pill form can find many appear within 12 to 24 hours after discontinuation of preparations, the more well known having 200 mg. caffeine intake, peak at roughly 48 hours, and usually Individuals worldwide consume about 76 mg of caf- last from one to five days, representing the time re- feine per day. Most people experience no behavioral quired for the number of adenosine receptors in the effects with less than 300 mg caffeine. Sleep is more brain to revert to “normal” levels, uninfluenced by sensitive and can be disrupted by 200 mg caffeine. At caffeine consumption. In United States, the preva- doses exceeding 1 g per day, susceptible individuals lence rates for caffeine-induced psychiatric disorders experience toxic effects. The caffeine content in some have not been well established. Mood disorders and common sources of caffeine is listed below (Table1). other substance abuses coexist with caffeine disorders. Some studies report 50% comorbidity.6,7 There Francis M. Torres, Caffeine Addiction MT(AMT), are four caffeine-induced psychiatric disorders Hematology Although caffeine does not produce with life- recognized by the DSM-IV, the diagnosis manual Technologist, Christus threatening health risks commonly associated with the of the American Psychiatric Association: caffeine in- Health Santa Rosa use of classic drugs of addiction such as cocaine, hero- toxication, caffeine-induced anxiety disorder, caf- City Centre, San in and nicotine, some caffeine users report becoming Antonio, TX feine-induced sleep disorder, and caffeine-related “addicted” to caffeine in the sense that they report an disorder not otherwise specified.8 (Table 2–6).

74 April 2009 • Continuing Education Topics & Issues Table 1. Caffeine Content of Foods and Drugs Article 353 Serving Caffeine Serving Caffeine 1 Clock Hour Product Product Size 1 (mg)2 Size 1 (mg)2 OTC Drugs Soft Drinks (cont’d.) NoDoz, maximum strength; Vivarin 1 tablet 200 Surge 12 ounces 51 Excedrin 2 tablets 130 Diet Coke 12 ounces 47 NoDoz, regular strength 1 tablet 100 Coca-Cola 12 ounces 45 Anacin 2 tablets 64 Dr. Pepper, regular or diet 12 ounces 41 Coffees Sunkist Orange Soda 12 ounces 40 Coffee, brewed 8 ounces 135 Pepsi-Cola 12 ounces 37 General Foods International Coffee, Orange 8 ounces 102 Barqs Root Beer 12 ounces 23 Cappuccino 7-UP or Diet 7-UP 12 ounces 0 Coffee, instant 8 ounces 95 Barqs Diet Root Beer 12 ounces 0 General Foods International Coffee, Cafe 8 ounces 90 Vienna Caffeine-free Coca-Cola or Diet Coke 12 ounces 0 Maxwell House Cappuccino, Mocha 8 ounces 60-65 Caffeine-free Pepsi or Diet Pepsi 12 ounces 0 General Foods International Coffee, Swiss Minute Maid Orange Soda 12 ounces 0 8 ounces 55 Mocha Mug Root Beer 12 ounces 0 Maxwell House Cappuccino, French Vanilla 8 ounces 45-50 Sprite or Diet Sprite 12 ounces 0 or Irish Cream Caffeinated Waters Maxwell House Cappuccino, Amaretto 8 ounces 25-30 ½ liter General Foods International Coffee, Java Water 125 8 ounces 26 (16.9 ounces) Viennese Chocolate Cafe ½ liter Krank 20 100 Maxwell House Cappuccino, decaffeinated 8 ounces 3-6 (16.9 ounces) Coffee, decaffeinated 8 ounces 5 ½ liter Aqua Blast 90 Teas (16.9 ounces) Celestial Seasonings Iced Lemon Ginseng 16-ounce ½ liter 100 Water Joe 60-70 Tea bottle (16.9 ounces) ½ liter Bigelow Raspberry Royale Tea 8 ounces 83 Aqua Java 50-60 (16.9 ounces) Tea, leaf or bag 8 ounces 50 Juices 16-ounce Snapple Iced Tea, all varieties 48 bottle Juiced 10 ounces 60 Lipton Natural Brew Iced Tea Mix, Frozen Desserts 8 ounces 25-45 unsweetened Ben & Jerry’s No Fat Coffee Fudge Frozen 1 cup 85 Lipton Tea 8 ounces 35-40 Yogurt 16-ounce Starbucks Coffee Ice Cream, assorted Lipton Iced Tea, assorted varieties 18-40 1 cup 40-60 bottle ﬂ avors Lipton Natural Brew Iced Tea Mix, Häagen-Dazs Coffee Ice Cream 1 cup 58 8 ounces 15-35 sweetened Häagen-Dazs Coffee Frozen Yogurt, fat-free 1 cup 40 16-ounce Häagen-Dazs Coffee Fudge Ice Cream, Nestea Pure Sweetened Iced Tea 34 1 cup 30 bottle low-fat Tea, green 8 ounces 30 1 bar Starbucks Frappuccino Bar 15 16-ounce (2.5 ounces) Arizona Iced Tea, assorted varieties 15-30 bottle Healthy Choice Cappuccino Chocolate Lipton Soothing Moments Blackberry Tea 8 ounces 25 Chunk or Cappuccino Mocha Fudge Ice 1 cup 8 Cream 16-ounce Nestea Pure Lemon Sweetened Iced Tea 22 bottle Yogurts, one container Tea, instant 8 ounces 15 Dannon Coffee Yogurt 8 ounces 45 Lipton Natural Brew Iced Tea Mix, diet 8 ounces 10-15 Yoplait Cafe Au Lait Yogurt 6 ounces 5 Lipton Natural Brew Iced Tea Mix, Dannon Light Cappuccino Yogurt 8 ounces < 1 8 ounces < 5 decaffeinated Stonyﬁ eld Farm Cappuccino Yogurt 8 ounces 0 Celestial Seasonings Herbal Tea, all 8 ounces 0 Chocolates or Candies varieties 1 bar Celestial Seasonings Herbal Iced Tea, 16-ounce Hershey’s Special Dark Chocolate Bar 31 0 (1.5 ounces) bottled bottle Perugina Milk Chocolate Bar with 1/3 bar Lipton Soothing Moments Peppermint Tea 8 ounces 0 24 Cappuccino Filling (1.2 ounces) Soft Drinks 1 bar Hershey Bar (milk chocolate) 10 Josta 12 ounces 58 (1.5 ounces) Mountain Dew 12 ounces 55 Coffee Nips (hard candy) 2 pieces 6

Adopted from the Nutrition Action Center for Science in the Public Interest14 * Serving sizes are based on commonly eaten portions, pharmaceutical instructions, or the amount of the leading-selling container size. For example, beverages sold in 16-ounce or half-liter bottles were counted as one serving

Continuing Education Topics & Issues • April 2009 75 A recently-released report from University of Massa- ment for caffeine-induced psychosis would simply be Article 353 1 Clock Hour chusetts Medical School noted 4,600 caffeine-relat- to stop further caffeine intake. ed calls to the American Association of Poison Con- trol Centers in 2005, the most recent data available. Caffeine-induced sleep disorder More than half involved people under 19, and 2,345 Caffeine-induced sleep disorder is a psychiatric required treatment in a health care facility.9 disorder that results from overconsumption of the stimulant caffeine, see Table 4. Caffeine’s effects on Caffeine intoxication sleep appear to be determined by a variety of factors Caffeine intoxication is currently defined by a including dose, the time between caffeine ingestion number of symptoms and clinical features that and attempted sleep, and individual differences in emerge in response to recent consumption of caf- sensitivity and/or tolerance to caffeine. The effects of feine. The potential for caffeine intoxication to cause caffeine on sleep are dose-dependent with higher clinically significant distress is reflected by the in- doses showing greater disruption on a number of clusion of caffeine intoxication as a diagnosis in sleep quality measures. Caffeine administered imme- DSM-IV (Diagnostic and Statistical Manual of Men- diately prior to bedtime or throughout the day has tal Disorders, Fourth Edition) (see Table 2). Al- been shown to delay sleep onset, reduce total sleep though DSM-IV diagnostic guidelines indicate that time, alter the normal stages of sleep, and decrease diagnosis is dependent on the recent daily consump- the reported quality of sleep. Caffeine-induced sleep tion of at least 250 mg of caffeine, the equivalent of disturbance is greatest among individuals who are not just two and a half cups of brewed coffee, intoxica- regular caffeine users. Although there is evidence for tion is most often observed at much higher doses of some tolerance to the sleep disrupting effects of caf- caffeine (i.e., > 500 mg). However, individual sensi- feine, complete tolerance may not occur and thus, tivity and tolerance are likely to influence the dose habitual caffeine consumers are still vulnerable to effects. A person with high sensitivity and little tol- caffeine-induced sleep problems.11 erance might show signs and symptoms of caffeine intoxication in response to doses of caffeine much Moderation Is the Key lower than a regular user. Treatment of severe caf- Caffeine is usually thought to be safe in moder- feine intoxication is generally supportive, providing ate amounts. Experts consider 200-300 mg of caf- treatment of the immediate symptoms, but if the pa- feine a day to be a moderate amount for adults. But tient has very high serum levels of caffeine, then consuming as little as 100 mg of caffeine a day can peritoneal dialysis, hemodialysis, or hemofiltration lead a person to become “dependent” on caffeine. may be required. In severe cases, death may result This means that someone may develop withdrawal from convulsions or an irregular heartbeat due to symptoms (like tiredness, irritability, and headaches) ventricular fibrillation brought about by effects of if he or she quits caffeine suddenly.12 Energy drinks caffeine on the cardiovascular system. are increasingly popular and caffeine is a main in- gredient contributing to the sense of arousal. Chil- Caffeine-induced anxiety disorder dren and adolescents can consume large amounts of In some individuals, the large amounts of caffeine caffeine in pursuit of a “buzz.” Even unwitting over- can induce anxiety severe enough to necessitate clin- consumption can produce the signs of caffeine in- ical attention. Studies have shown that high dietary toxication. Parents should encourage children to doses of caffeine (200 mg or more) increase anxiety carefully read the labels and avoid consuming excess ratings and induce panic attacks in the general popu- amounts of caffeine.13 Only petroleum exceeds cof- lation. Individuals with panic and anxiety disorders fee as a globally traded commodity, and commerce are especially sensitive to the effects of caffeine. Al- and history of the United States are closely linked to though highly anxious individuals tend to be more tea consumption. Soft drinks now rank as the most likely to limit their caffeine use, not all individuals popular beverage in the United States, and most con- with anxiety problems naturally avoid caffeine, and tain caffeine. Beverage trade groups estimate the an- some may fail to recognize the role that caffeine is nual per capita soft drink consumption at 56 gallons. playing in their anxiety symptoms. This caffeine-in- Research and worldwide beverage history confirm duced anxiety disorder can take many forms, from the safety of moderate caffeine consumption in generalized anxiety to panic attacks, obsessive-com- healthy individuals. Caffeine is the only addictive pulsive symptoms, or even phobic symptoms (see psychoactive substance that has overcome resistance Table 3). Because this condition can mimic organic and disapproval around the world to the extent that it mental disorders such as panic disorder, generalized is freely available almost everywhere, unregulated, anxiety disorder, bipolar disorder, or even schizo- sold without license, offered over the counter in phrenia,10 a number of medical professionals believe tablet and capsule form, and even added to beverages caffeine-intoxicated people are routinely misdiag- intended for children. nosed and unnecessarily medicated when the treat-

76 April 2009 • Continuing Education Topics & Issues Table 2. DSM-IV criteria for caffeine Table 4. DSM-IV criteria for caffeine-induced Article 353 intoxication sleep disorder 1 Clock Hour Recent consumption of caffeine, usually in • A prominent disturbance in sleep occurs that is excess of 250 mg (more than 2-3 cups of brewed sufficiently severe to warrant independent coffee) clinical attention. • Demonstration of 5 or more of the following • There is evidence from the history, physical signs during or shortly after caffeine use: examination, or laboratory findings that the • Restlessness sleep disturbance is the direct physiological consequence of caffeine consumption. • Nervousness • The disturbance is not better accounted for by • Excitement another mental disorder. • Insomnia • The disturbance does not occur exclusively • Flushed face during the course of a delirium. • Diuresis • The disturbance does not meet the criteria for breathing-related sleep disorder or narcolepsy. • Gastrointestinal disturbance • The sleep disturbance causes clinically • Muscle twitching significant distress or impairment in social, • Rambling flow of thought and speech occupational, or other important areas of • Tachycardia or cardiac arrhythmia functioning. • Periods of inexhaustibility • Psychomotor agitation • The above symptoms cause clinically significant distress or impairment in social, Table 5. DSM-IV criteria for caffeine-related occupational, or other important areas of disorder NOS functioning. • The symptoms are not due to a general • This includes any caffeine disorder other than medical condition and are not better those previously listed. accounted for by another mental disorder, • Symptoms of caffeine withdrawal that are not such as an anxiety disorder. currently an officially recognized diagnosis are present.

Table 3. DSM-IV criteria for caffeine-induced anxiety disorder

• Prominent anxiety predominates in the clinical picture. • There is evidence from the history, physical examination, or laboratory findings suggesting that the anxiety developed within 1 month of caffeine intoxication or withdrawal or that medications containing caffeine are etiologically related to the disturbance. • The disturbance is not better accounted for by an anxiety disorder that is not substance- induced. • The disturbance does not occur exclusively during the course of a delirium. • The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Continuing Education Topics & Issues • April 2009 77 8. American Psychiatric Association. Diagnostic and Statistical Article 353 References 1. Maughan, RJ; Griffin J (2003). “Caffeine ingestion and fluid Manual of Mental Disorders, Fourth Edition Text Revision (DSM- 1 Clock Hour balance: a review.”. J Human Nutrition Dietetics 16: 411-20. IV-TR). Washington, DC: 2000:212-5, 708-9 2. Nehlig, A; Daval JL, Debry G (1992 May-August). “Caf- 9. Church, Richard MD. Interviewed from CBS news NEW feine and the central nervous system: Mechanisms of action, bio- YORK, July 17, 2008 Available at: http://www.cbsnews.com/sto- chemical, metabolic, and psychostimulant effects”. Brain Res Rev ries/2008/07/17/earlyshow/health/main4267600.shtml. Accessed 17 (2): 139-70. doi:10.1016/0165-0173(92)90012-B. PMID April, 2009 1356551. 10. Shannon, MW; Haddad LM, Winchester JF (1998). Clini- 3. What's your poison: caffeine”. Australian Broadcasting Cor- cal Management of Poisoning and Drug Overdose, 3rd ed.. ISBN poration. 1997. 0-7216-6409-1. http://www.abc.net.au/quantum/poison/caffeine/caffeine.htm. Ac- 11. Caffeine pharmacology and clinical effects. In: Graham cessed April, 2009 A.W., Schultz T.K., Mayo-Smith M.F., Ries R.K. & Wilford, B.B. 4. Frary CD, Johnson RK, Wang MQ. Food sources and in- (Adapted from Griffiths, R.R., Juliano, L.M., & Chausmer, A.L. takes of caffeine in the diets of persons in the United States. J Am (2003). Diet Assoc. Jan 2005;105(1):110-3. 12. Teens Health from Nemours. Available at http://kid- 5. Juliano, L M (2004-09-21). “A critical review of caffeine shealth.org/teen/drug_alcohol/drugs/caffeine.html/. Accessed withdrawal: empirical validation of symptoms and signs, inci- April, 2009 dence, severity, and associated features”. Psychopharmacology 176 13. R. Gregory Lande (2005-07-07). “Caffeine-Related Psy- (1): 1-29. doi:10.1007/s00213-004-2000 chiatric Disorders”. eMedicine. http://www.emedicine.com/med/ 6. Lande RG, Labbate LA. Caffeine use and plasma concentra- topic3115.htm. Accessed April, 2009 tions in psychiatric outpatients. Depress Anxiety. 1998;7(3):130-3. 14. National Coffee Association, National Soft Drink Associa- 7. Nehlig A. Are we dependent upon coffee and caffeine? A re- tion, Tea Council of the USA, and information provided by food, view on human and animal data. Neurosci Biobehav Rev. Mar beverage, and pharmaceutical companies and J.J. Barone, H.R. 1999;23(4):563-76. Roberts (1996) “Caffeine Consumption.” Food Chemistry and Tox- icology, vol. 34, pp. 119-129.

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