CAFFEINE-RELATED DIS0RDERS

NIHARIKA APURVA
CHAITALI PRADEEPTI
SPANDANA AATIKA
DAMINI MUSKAN
HARSHEEN KAAVYA
DIPLOMA AASHI
 CAFFEINE
Caffeine is the most widely consumed psychoactive substance in the world. Caffeine is found in more than 60 species of
plants and belongs to the methylxanthine class of alkaloids, which also includes theobromine (found in chocolate) and
theophylline (often used in the treatment of asthma).
In the United States, 87 percent of children and adults consume foods and beverages containing caffeine. Caffeine affects
various neurobiological and physiological systems and produces significant psychological effects. Caffeine is not
associated with any life-threatening illnesses, but its use can result in psychiatric symptoms and disorders. The habitual use
of caffeine and its widely accepted integration into daily customs can lead to an underestimation of the role that caffeine
may play in one's daily life and can make the recognition of caffeine-associated disorders particularly challenging.
Hence, it is important for the clinician to be familiar with caffeine, its effects, and problems that can be associated with its
use.
Caffeine use is associated with disorders : caffeine intoxication, caffeine withdrawal, other caffeine induced disorders
(caffeine induced anxiety disorder and caffeine induced sleep disorder), and unspecified caffeine-related disorders.
 CAFFEINE INTOXICATION
DSM-5 Diagnostic Criteria

A. Recent consumption of caffeine (typically a high dose well in excess of 250 mg).
B. Five (or more) of the following signs or symptoms developing during, or shortly after, caffeine use:
(1) restlessness
(2) nervousness
(3) excitement
(4) Insomnia
(5) flushed face
(6) diuresis
(7) gastrointestinal disturbance
(8) muscle twitching
(9) rambling flow of thought and speech
(10) tachycardia or cardiac arrhythmia
(11) periods of inexhaustibility
(12) psychomotor agitation

C. The symptoms in Criterion B cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
D. The signs or symptoms are not attributable to another medical condition and are not better explained by another mental disorder, including intoxication
• Caffeine intoxication is an over-stimulation of the central nervous system caused by a high dose of caffeine.
• Coffee is the most common source of a high intake of caffeine. Other sources of caffeine are tea, energy drinks, soda, chocolate, analgesics, and
cold remedies. Caffeine is taken to improve mood, concentration, alertness, and cognitive function.
• Although caffeine intoxication typically does not last for more than a day, very high doses can require immediate medical attention and be lethal.
The most common complaint of caffeine intoxication is interference with sleep. Caffeine intoxication is a growing problem in younger age
groups due to the popularity of energy drinks among adolescents and students. For an overdose, a person must ingest more than 250 mg,
according to DSM-5. An 8-6 ounce energy drink has 70-180 mg, an energy shot 171 mg, and the mega 24-ounce size can have as high as 500
mg of caffeine. A cup of coffee contains 100-200 mg (Child & de Wit, 2011).
• Symptoms of caffeine intoxication can include nervousness, irritability, increased urination, stomach upset, and hypertension. For a diagnosis of
caffeine intoxication under DSM-5, an individual must have consumed a high dose of caffeine in excess of 250 mg and display five or more of
the following symptoms: restlessness, nervousness, excitement, insomnia, flushed face, diuresis, gastrointestinal disturbance, muscle twitching,
rambling flow of thought and speech, tachycardia or cardiac arrhythmia, periods of high energy, or psychomotor agitation.
• These symptoms must cause distress or impairment in social, occupational and other forms of functioning, and not be associated with other
substance, mental disorder or medical condition. Children or the elderly may experience caffeine intoxication at lower doses.
 CAFFEINE WITHDRAWAL
Diagnostic Criteria
A. Prolonged daily use of caffeine.
B. Abrupt cessation of or reduction in caffeine use, followed within 24 hours by three or
more of the following signs or symptoms:
Headache
Marked fatigue or drowsiness.
Dysphoric mood, depressed mood, or irritability.
Difficulty concentrating
Flu-like symptoms (nausea, vomiting, or muscle pain/stiffness)
C. The signs or symptoms in Criterion B cause clinically significant distress or
impairment in social, occupational, or other important areas of functioning.
D. The signs or symptoms are not associated with the physiological effects of another
medical condition (e.g. Migraine, viral illness) and are not better explained by another
mental disorder, including intoxication or withdrawal from another substance.
• Diagnostic Features
• The essential feature of caffeine withdrawal is the presence of a characteristic
withdrawal syndrome that develops after abruptly or substantially reducing prolonged
caffeine intake. The withdrawal symptoms are indicated by three or more of the
following symptoms- headache, fatigue or drowsiness, dysphoric, depressed or
irritable mood, inability to concentrate, and flu-like symptoms like nausea, vomiting,
or muscle pain or stiffness. The symptoms cause significant distress or impairment
and are not attributable to another medical condition and not better explained by
another mental disorder.
• Headache is the characteristic feature of caffeine withdrawal and it may be diffuse,
gradual, throbbing, severe, and sensitive to movement. Other symptoms may occur in
the absence of a headache as well. Since caffeine ingestion is often integrated into
social customs and dietary practices, some people may be unaware of their physical
dependence on caffeine. Therefore, caffeine withdrawal symptoms could be
unexpected or misattributed to other causes like flu or migraine. Caffeine withdrawal
symptoms may occur when individuals are required to avoid certain foods or drinks
before a medical procedure or when a regular dose is missed because of a change in
routine.
OTHER CAFFEINE RELATED DISORDERS
• Caffeine induced anxiety disorder
• Caffeine induced sleep disorder
Adolescent caffeine consumption increases adulthood anxiety-
related behavior

Caffeine is a commonly used psychoactive substance and

consumption by children and adolescents continues to rise. Here,
we examine the lasting effects of adolescent caffeine consumption
on anxiety-related behaviors. Adolescent male rats consumed
caffeine for 28 consecutive days. Age-matched control rats
consumed water. Behavioral testing for anxiety-related behavior
began in adulthood 7 days after removal of caffeine. Adolescent
caffeine consumption enhanced anxiety-related behavior in an
open field, social interaction test, and elevated plus maze. Similar
caffeine consumption in adult rats did not alter anxiety-related
behavior after caffeine removal. these findings suggest that
adolescent caffeine consumption may increase vulnerability to
psychiatric disorders including anxiety-related disorders.
Sleep disturbances in nicotine, caffeine, alcohol, cocaine, opioid,
and cannabis use

• Sleep disturbances are common consequences of substance use

disorders and are likely found in primary care as well as in specialty
practices. The aim of this review was to evaluate the effects of the
most frequently used substances—nicotine, alcohol, opioids, cocaine,
caffeine, and cannabis—have on sleep parameters.
• We only included studies that assessed sleep disturbances using
polysomnography and reviewed the effects of these substances on six
clinically relevant sleep parameters: Total sleep time, sleep onset
latency, rapid‐eye movement, REM latency, wake after sleep onset,
and slow wave sleep.
• Our review indicates that these substances have significant impact on
sleep and that their effects differ during intoxication, withdrawal, and
chronic use. Many of the substance‐induced sleep disturbances
overlap with those encountered in sleep disorders, medical, and
psychiatric conditions. Sleep difficulties also increase the likelihood of
ETIOLOGY

• SUBJECTIVE EFFECTS AND REINFORCEMENTS

Certain doses of caffeine can produce a profile of subjective effects in humans that is
generally identified as pleasurable such as increased energy and concentration, and
motivation to work. In addition, these doses of caffeine produce decreases in ratings
of feeling sleepy or tired.

• GENETICS AND CAFFEINE USE

Some genetic predisposition may exist to continued coffee use after exposure to
coffee. Researches have shown higher concordance rates for monozygotic twins for
total caffeine consumption, heavy use, caffeine tolerance, caffeine withdrawal, and
caffeine intoxication.
• AGE AND GENDER
Some evidence suggests that middle-aged people may use more caffeine, although
caffeine use in adolescents is not uncommon. No evidence indicates that caffeine
use differs between men and women.

• OTHER PSYCHOLOGICAL FACTORS

o Cigarette smokers consume more caffeine than non smokers.
o Heavy use and clinical dependence on alcohol is associated with heavy use and
clinical dependence on caffeine as well.
o Individuals with anxiety disorders tend to report lower levels of caffeine use,
although one study showed that a greater proportion of heavy caffeine consumers
also use benzodiazepines.
o Several studies have also shown high daily amounts of caffeine use in psychiatric
patients.
 ETIOLOGY
• The immediate cause of caffeine intoxication and other caffeine-related disorders
is consumption of an amount of caffeine sufficient to produce the symptoms
specified by DSM-5 as criteria for the disorder.
• The precise amount of caffeine necessary to produce symptoms varies from
person to person depending on body size and degree of tolerance to caffeine.
• Tolerance of the stimulating effects of caffeine builds up rapidly in humans; mild
withdrawal symptoms have been reported in persons who were drinking as little as
one to two cups of coffee per day.
• Some people may find it easier than others to consume large doses of caffeine
because they are insensitive to its taste.
• Caffeine tastes bitter to most adults, which may serve to limit their consumption
of coffee and other caffeinated beverages. Slightly more than 30% of the American
population, however, has an inherited inability to taste caffeine.
COMORBIDITY

• Typical dietary doses of caffeine have not been consistently associated

with medical problems. However, heavy use
• (e.g., >400 mg) can cause or exacerbate anxiety and somatic
symptoms and gastrointestinal distress. With acute, extremely high
doses of caffeine, grand mal seizures and respiratory failure may result
in death.
• Excessive caffeine use is associated with depressive disorders, bipolar
disorders, eating disorders, psychotic disorders, sleep disorders, and
substance-related disorders, whereas individuals with anxiety
disorders are more likely to avoid caffeine.
PROGNOSIS

1. Environmental : this disorder is often seen among

individuals who use caffeine less frequently or in those who
have recently increased their caffeine intake by a substantial
amount. Oral contraceptives decrease the elimination of
caffeine and consequently may increase the risk of
intoxication.
2. Genetic and physiological : these may affect risk of caffeine
intoxication.
PREVALENCE

• The prevalence in the general population of caffeine intoxication is

unclear.

• In US, the general population has a high level of caffeine consumption

(average intake of 200mg/day).

• About 85% of the population consumes caffeine on a daily basis.

• The prevalence of caffeine withdrawal syndrome is unclear.

DIFFERENTIAL DIAGNOSIS OF CAFFEINE
INTOXICATION
• Other mental disorders
Caffeine intoxication may be characterized by symptoms that resemble
primary mental disorders. To meet criteria for caffeine intoxication the
symptoms must not be associated with another medical condition or
another mental disorder , such as anxiety disorder , that could better
explain them. Disorders that can cause a clinical picture similar to
caffeine intoxication are , manic episodes, panic disorder, generalised
anxiety disorder, sedative, hypnotic, or anxiolytic withdrawal or tobacco
withdrawal, sleep disorders and medication induced side effects (e.g.
akathisia).
• Other caffeine-induced disorders
The temporal relationship of the symptoms to increased caffeine use or
to abstinence from caffeine helps to establish the diagnosis. Disorders
like caffeine-induced anxiety disorder and caffeine-induced sleep
disorder are differentiated from caffeine intoxication , with onset
during intoxication and by the fact that these two disorders are in
excess and are severe enough to warrant independent clinical attention.
Differential diagnosis of caffeine withdrawal

• Other medical disorders and medical side effects

Caffeine withdrawal can be similar to migraine and other headache
disorders, viral illnesses, sinus conditions, tension, other drug
withdrawal states ( e.g. cocaine ) and medication side effects. The final
determination of caffeine withdrawal should rest on determination of the
pattern and amount consumed, the time interval between caffeine
abstinence and onset of symptoms.
TREATMENT FOR CAFFEINE-RELATED DISORDERS

1) Analgesics, like Aspirin can be used to control the headaches and muscle pains caused by
caffeine withdrawal.
2) To deal with caffeine withdrawal symptoms, benzodiazepines can also be used. However, if
benzodiazepines are used, they should be used in small dosages for about 7-10 days.
3) The first step in reduction or elimination of caffeine is to keep a track of daily consumption
levels. To accomplish this, all sources of caffeine in the patient’s diet should be accurately
recognized.
The second step should comprise of a mutual decision by the patient and clinician regarding the
systematic reduction of caffeine. It is advisable to start with a 10% decrement, initially. The
patient can also be motivated to consume decaffeinated beverages.
Every patient should have a unique individualized treatment plan catering to his physiological
needs so that withdrawal symptoms can be minimised.
4) It is advised not to stop caffeine consumption abruptly as withdrawal symptoms are likely to
develop in greater intensity with sudden discontinuation of caffeine.
REVIEW OF LITERATURE
• A study on caffeine consumption and its association with stress and appetite among call centre
employees in Mumbai city, India
• Lakshmi B. Kale, Kejal Joshi Reddy (2017)
• Background: Caffeine is a widely consumed chemical having controversial effects. Caffeine may
interact with the satiety and may be associated with stress levels. The frequency of caffeine
consumption among call centre employees is known to be high. The aim of the study was to assess the
caffeine intake, and it's association with appetite and stress levels among call centre employees aged
between 25-35 years
• Methods: A cross sectional study with purposive sampling was done from a call centre at Mumbai,
India. Anthropometric measurements and structured questionnaires were used for data collection.
• Results: The average caffeine intake was 200mg/day through coffee and 150mg/day through tea
among the habitual consumers. As per the scoring categories of adapted appetite questionnaire
(CNAQ), 54.7% of the participants were at risk to abnormally low appetite. The stress questionnaire
results showed that 84.6% of the participants were at high risk to stress. Significant negative
association was found between appetite score and coffee consumption (r=0.55,p<0.001), coffee
consumption plus smoking (r=0.476,p<0.05) and tea consumption (r=0.300, p<0.05) respectively. No
significant association was observed between caffeine consumption and stress.
• Conclusions: Caffeine had a negative impact on the appetite levels. Smoking was observed to worsen
the effect of caffeine on appetite.
REVIEW OF LITERATURE

• Nawrot , Jordan et.al (2003) conducted a research on effect of caffeine on human

health. According to this review it is concluded that for the healthy adult population ,
moderate daily caffeine intake at a dose level up to 400 mg day is not associated
with adverse effects such as general toxicity , cardiovascular effects, effects on bone
status and calcium balance . The data also show that reproductive aged women and
children are ‘at risk’ subgroups who may require specific advice on moderating their
caffeine intake.
• Pooter , Stijnman et.al (2018) conducted a research on the effect of caffeine on sleep
and behavior in nursing home residents with dementia living in 1 dementia special
care unit , caffeine was gradually eliminated in the afternoon and evening . Pre-
intervention and post – intervention scores were recorded. The result found was that
a significant improvement in sleep scores and apathy was found after eliminating
caffeine intake in the afternoon and evening. No significant changes occurred in
agitation/aggression, irritability and aberrant motor behavior.
REFERENCES

• Adolescent caffeine consumption increases adulthood anxiety-related

behavior Volume 67, May 2016, Pages 40-50
• Polysomnographic sleep disturbances in nicotine, caffeine, alcohol,
cocaine, opioid, and cannabis use: A focused review
• Alexandra N. Garcia BHS, MD Candidate , Ihsan M. Salloum MD,
MPH First published: 08 September 2015