By Max Stanley Chartrand, Ph.D. (Behavioral Medicine)
Abstract: Arguably the world's most psychoactive drug,
products containing caffeine as traded commodities are
surpassed only by sales of petroleum products. Caffeine
consumption has increased among all age groups, even
down to toddlers innocently sipping on a 16 oz. Coca
Colas, so much so that growing attention is turning to
both the short-term and long-term health effects of
caffeine consumption. This paper explores the negative
psychological and physiological impact caffeine can have
on various subsets of the population, and the need for
greater consumer and professional education to better
recognize these effects. In particular, alarm over the
growing incidence of Caffeine Intoxication and Caffeine
Withdrawal, including caffeine-induced anxiety, are fast
making their way into recognized clinical diagnosis and
treatment protocols, including the DSM-IV-TR (APA,
2000). Diagnoses for these conditions may be made based
upon case history and observation of possible secondary
conditions. Treatment involves avoidance and/or
reduction of caffeine, counseling, and a holistic
approach to improved health.
Etiology of Caffeine Intoxication (CI) arises from
pharmacological stimulation of the human Central Nervous
System (CNS), heart rate, voluntary muscle control, and
other physical processes, such as diuresis and gastric
secretions (Lande, 2005). Increased systolic blood
pressure and analgesic effects are also noted in
physical effects of caffeine ingestion (Keogh and
Chaloner, 2002). Psychological and physical effects
include an array of effects, from which indications of
five or more may constitute a diagnosis of CI during or
after caffeine use (DSM-IV-TR, 2000):
Nervousness
Excitement
Restlessness
Insomnia
Flushed face
Diuresis
Muscle Twitching
Gastrointestinal disturbance
Rambling thought or speech
Tachycardia or cardiac arrhythmia
Periods of inexhaustibility
Psychomotor agitation
Differentiating criteria involve whether the above
symptoms are serious enough to cause ¡§clinically
significant distress or impairment in social,
occupational, and other important areas of functioning¡¨
(Lande, 2005, p. 3). Most effects are expressed in terms
of behavioral patterns, but anxiety is likely the most
common manifestation, followed by withdrawal symptoms of
mild depression, headache, irritability, difficulty
concentrating, and flu-like symptoms. Hence, Caffeine
Withdrawal (CW) tends to be the after-effects to CI,
lasting up to 2-3 days or longer following cessation of
caffeine ingestion (WebMD, 2004).
The degree of symptoms appear to be based upon four main
factors: 1) one¡¦s body weight, 2) the dose consumed, 3)
individual tolerance or vulnerability to caffeine, and
4) any pre-existing psychiatric and/or medical
conditions. Peak plasma levels present about one hour
after ingestion, with a half-life of 4-6 hours,
depending upon body weight. Caffeine absorbs readily
into body fluids and tissues, and may stimulate the
body¡¦s central nervous system over a period of up to 12
hours. Lingering effects at the end of this cycle can
cause irritability and insomnia in some individuals for
days afterwards. Trait personality disorder subsets tend
to show the most dramatic psychological and emotional
responses to psychostimulation, and therefore must be
diagnosed within an individual context. For that reason,
evidence suggests frequent mis- or over-diagnosis for
some psychiatric non- or pre-existing psychological
conditions, such obsessive-compulsive disorder (OCD),
schizophrenia, panic or anxiety disorder, attentional
deficit with hyperactivity (ADHD), hypochondria, somatic
delusions, post-menstrual syndrome, anorexia, etc. In
other words, CI may exacerbate or present a false
positive in some individuals with these conditions
(Bailey, 2006; Whalen, 2005; Chartrand, 2004). Other
studies link CI and CW with cases of mild clinical
depression (Werbach, 1999).
Promoting increased public health threats, worldwide
commercial interests appear to be fervently working
toward increasing market size and reach of those most
susceptible to caffeine addiction: The very young. One
of the most brazen attempts to grow a larger market of
consumers is the widespread practice of negotiating
lucrative two-way contracts between U.S. public school
districts and commercial bottling companies, such as
Coca Cola, Pepsi, etc. to provide soft drink vending
machines throughout the hallways of the schools
everywhere, especially sales of high-content popular
drinks. Many of these popular drinks rival the notorious
Red Bull drinks with 4, 5, even 6 times the caffeine
contained in Coca Cola. Consequently, caffeinated drink
sales to school age children have exploded to record
highs and have raised considerable concerns among health
agencies and professionals. While rising obesity and
pre-diabetic tendency in youth garner much concern
today, there are also those concerned over deleterious
behavioral effects as a result of exploding caffeine
dependency, which often translates into disciplinary and
academic deficiency issues (Abigail Trafford, 1999).
American University conducted a recent study in which
its investigators concluded that the results ¡§shows
very nicely that the effects of caffeine withdrawal are
consistent, that several symptoms are of large
magnitude, and that a minority of people cannot perform
daily functions when they go without caffeine¡¨ (WebMD,
2004, p. 1). Whereas 100 milligrams is enough to evoke
marked withdrawal symptoms, the average person in the
U.S. today consumes 280 milligrams daily, or the
equivalent of two cups of coffee or 3-5 soft drinks.
Increased worldwide sales of coffee, chocolate, and
over-the-counter headache and dietary products
containing large amounts of caffeine attest to
saturation into all age groups and walks of life (Dawidowski,
2002).
Interactions with other drugs is also of grave concern,
especially in non-medical uses, such as over-the-counter
weight loss products with phenylpropanolamine, and
smoking cessation products containing the active
ingredient of nicotine (Choice Changes, 2003; Swanson,
1993). Cases of asthma and bipolar symptoms have
reportedly been aggravated or triggered by caffeine
intake (Anonymous, 2006; Answers.com, 2006; Whetsell and
Shapira, 1993). Sleep can be interrupted by consumption
of about 200 mg. in most people, while toxic effects are
prevalent in susceptible individuals at 1 gram or more
per day. Prolonged use of caffeine, especially in
exclusion of adequate nutrition, and/or abrupt
cessation, may trigger serious toxic reactions in such
individuals (Lande, 2005; Baker, 2000; Lamberg, 1999).
Testing for caffeine toxicity mostly involves case
history and by eliminating other causes, such as
concomitant drug-use. Blood tests for caffeine are
generally not practical or even helpful in diagnosis.
Thyroid studies for developing hypothyroidism may shed
further light. Otherwise, symptoms such as insomnia,
cardiac irregularities, and other symptoms described
above may be factored into a diagnosis of either
caffeine intoxication or caffeine withdrawal, depending
upon which side of use history and symptomology
diagnosis is rendered. Diagnoses for psychiatric
conditions relative to those described in DSM-IV-TR
(2000) can help identify trait personality and other
mental disorders.
While Mosby¡¦s Manual of Diagnostic and Laboratory Tests
(Pagana and Pagana, 2002) does not list any specific
tests for CI or CW, there are several tests that may
reveal secondary chronic disease effects that can arise
from long-term caffeine intoxication, such as:
„X Chronic mild to moderate dehydration via measurement
of Antidiuretic hormone ADH tests, compared to plasma
sodium levels.
„X Immunosuppression and/or adrenal insufficiency or
depletion via C-reactive and Adrenocoticotropic hormone
stimulation (ACTH Stimulation) tests
„X Caffeine-triggered allergy or asthmatic response via
tests for IgE, IgG, etc.
„X Tests for inflammation via cytokines IL-4, IL-5, and
IL-6
Treatment may consist of avoidance and/or significant
reduction in caffeine ingestion, and by addressing any
of the above (secondary) conditions. One must keep an
eye toward gradual health improvements, and hence,
improvements in the secondary conditions, as well, that
may require adjustments or gradual decreases in
medications. Counseling and/or psychotherapy relative to
functional and psychological issues will also be needed
in cases of trait personality disorders. But, looking at
the larger picture of public health concerns, consumer
education, as well as advancement in diagnostic and
treatment regimens, may actually serve to be the best
remediation for all concerned.
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