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 disor- ders. 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.