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Are we addicted to Are we addicted to coffee?coffee?The (Possible) Necessity of Caffeine The (Possible) Necessity of Caffeine Dependence Syndrome in the DSMDependence Syndrome in the DSM

Amanda SmallwoodAmanda Smallwood100067083100067083

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Caffeine BackgroundCaffeine Background

Average American’s caffeine intake is 200 mg/day, and Average American’s caffeine intake is 200 mg/day, and up to 30% of Americans consume 500 mg or more per up to 30% of Americans consume 500 mg or more per day. day.

Coffee, brewed = 100-140 mg/8oz. Coffee, brewed = 100-140 mg/8oz. Coffee, instant = 65-100 mg/8oz.Coffee, instant = 65-100 mg/8oz. Tea = 40-100 mg/8oz.Tea = 40-100 mg/8oz. Caffeinated soda = 45 mg/12oz.Caffeinated soda = 45 mg/12oz. Over-the-counter cold remedies = 25-50 mg/tabletOver-the-counter cold remedies = 25-50 mg/tablet Antidrowsiness pills = 100-200 mg/tabletAntidrowsiness pills = 100-200 mg/tablet Weight-loss aids = 75-200 mg/tabletWeight-loss aids = 75-200 mg/tablet Chocolate = 5 mg/chocolate barChocolate = 5 mg/chocolate bar

(DSM-IV, pg 231)(DSM-IV, pg 231)

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What is an addiction?What is an addiction?

Some argue that addictive drugs Some argue that addictive drugs engender “compulsion” or overwhelming engender “compulsion” or overwhelming involvement that takes over all life activity involvement that takes over all life activity to the exclusion of other interests. (so to the exclusion of other interests. (so caffeine wouldn’t qualify)caffeine wouldn’t qualify)

Others say the substance has to have Others say the substance has to have reinforcing effects, and produce harmful reinforcing effects, and produce harmful effects on the user and the society. (so, effects on the user and the society. (so, maybe)maybe)

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Substance-Related Substance-Related DisordersDisorders

Substance Use DisordersSubstance Use Disorders Substance DependenceSubstance Dependence Substance AbuseSubstance Abuse

Substance-Induced DisordersSubstance-Induced Disorders Substance IntoxicationSubstance Intoxication Substance WithdrawalSubstance Withdrawal Substance-Induced DeliriumSubstance-Induced Delirium Substance-Induced Mood DisorderSubstance-Induced Mood Disorder Substance-Induced Sexual Dysfunction…..Substance-Induced Sexual Dysfunction…..

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What is Substance What is Substance Dependence?Dependence?

““A maladaptive pattern of substance use, leading to clinically significant A maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by 3 or more of the following, impairment or distress, as manifested by 3 or more of the following, occuring at any time in the same 12-month period:occuring at any time in the same 12-month period: 1) Tolerance, as defined by either a need for markedly increased amounts of 1) Tolerance, as defined by either a need for markedly increased amounts of

the substance to achieve intoxication or desired effect, or markedly diminished the substance to achieve intoxication or desired effect, or markedly diminished effect with continued use of the same amount of the substanceeffect with continued use of the same amount of the substance

2) Withdrawal2) Withdrawal 3) the substance is often taken in larger amounts or over a longer period of 3) the substance is often taken in larger amounts or over a longer period of

time than was intendedtime than was intended 4) there is a persistent desire or unsuccessful efforts to cut down or control 4) there is a persistent desire or unsuccessful efforts to cut down or control

substance usesubstance use 5) a great deal of time is spent in activities necessary to obtain the substance, 5) a great deal of time is spent in activities necessary to obtain the substance,

use the substance, or recover from its effectsuse the substance, or recover from its effects 6) important social, occupational, or recreational activities are given up or 6) important social, occupational, or recreational activities are given up or

reduced because of substance usereduced because of substance use 7) the substance use is continued despite knowledge of having a persistent or 7) the substance use is continued despite knowledge of having a persistent or

recurrent physical or psychological problem that is likely to have been caused recurrent physical or psychological problem that is likely to have been caused or exaccerbated by the substance “or exaccerbated by the substance “ (DSM-IV 197)(DSM-IV 197)

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What is Substance What is Substance dependence?dependence?

Specifiers: Specifiers: With Physiological Dependence With Physiological Dependence

Tolerance (“need for greater amounts of substance Tolerance (“need for greater amounts of substance to achieve desired effect”)to achieve desired effect”)

Withdrawal (“maladaptive behavioural change, with Withdrawal (“maladaptive behavioural change, with physiological and cognitive concomitants, that physiological and cognitive concomitants, that occurs when blood or tissue concentrations of a occurs when blood or tissue concentrations of a substance decline in an individual who had substance decline in an individual who had maintained prolonged heavy use of the substance” maintained prolonged heavy use of the substance” DSM-IV pp194)DSM-IV pp194)

Without Physiological DependenceWithout Physiological Dependence

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What is Substance What is Substance Abuse?Abuse?

““A maladaptive pattern of substance use A maladaptive pattern of substance use leading to clinically significant impairment or leading to clinically significant impairment or distress as manifested by one or more of the distress as manifested by one or more of the following, occurring within a 12-month period:following, occurring within a 12-month period: 1) recurrent substance use resulting in a failure to 1) recurrent substance use resulting in a failure to

fulfill major role obligations at work, school, or homefulfill major role obligations at work, school, or home 2) recurrent substance use in situations in which it is 2) recurrent substance use in situations in which it is

physically hazardousphysically hazardous 3) recurrent substance-related legal problems3) recurrent substance-related legal problems 4) continued substance use despite having 4) continued substance use despite having

persistent or recurrent social or interpersonal persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of problems caused or exacerbated by the effects of the substancethe substance

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Current DSM-IV Current DSM-IV DiagnosesDiagnoses Caffeine Withdrawal SyndromeCaffeine Withdrawal Syndrome Caffeine IntoxicationCaffeine Intoxication Other Caffeine-Induced Disorders (diagnosed Other Caffeine-Induced Disorders (diagnosed

when symptoms exceed those usually associated when symptoms exceed those usually associated with Caffeine Intoxication)with Caffeine Intoxication) Caffeine-Induced Anxiety DisorderCaffeine-Induced Anxiety Disorder Caffeine-Induced Sleep DisorderCaffeine-Induced Sleep Disorder

Acute doses exceeding 10g (approx. 100 cups of Acute doses exceeding 10g (approx. 100 cups of coffee) can result in grand mal seizures and coffee) can result in grand mal seizures and respiratory failure which may result in death.respiratory failure which may result in death.

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Caffeine’s Properties of Caffeine’s Properties of Physical DependencePhysical Dependence

Acts as reinforcer (leads to a release of dopamine in Acts as reinforcer (leads to a release of dopamine in the prefrontal cortex, Nehlig, 1999)the prefrontal cortex, Nehlig, 1999)

Hughes et al (1992) found that some coffee and soda Hughes et al (1992) found that some coffee and soda drinkers reliably self-administered caffeinated drinkers reliably self-administered caffeinated beverages in preference to decaffeinated in a double-beverages in preference to decaffeinated in a double-blind test.blind test.

Tolerance to some subjective effects of caffeine seems Tolerance to some subjective effects of caffeine seems to occur, but complete tolerance to many effects of to occur, but complete tolerance to many effects of caffeine on the central nervous system is rarely seen caffeine on the central nervous system is rarely seen (Nehlig, 1999).(Nehlig, 1999).

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Nehlig (1999) concluded that although caffeine fulfils some of the criteria for drug dependence and shares with amphetamines and cocaine some effects of the cerebral dopaminergic system, it does not act on the dopaminergic structures related to reward, motivation and addiction.

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Clinical Dependence, as Clinical Dependence, as Well?Well?

Patterns of consumptionPatterns of consumption Many feel it’s the same syndrome but milder Many feel it’s the same syndrome but milder

than heroin or cocaine. than heroin or cocaine. But, since effects are less pronounced, it But, since effects are less pronounced, it

cannot be equated with other drugs of cannot be equated with other drugs of dependence.dependence.

Many people show habitual use, but it’s hard to Many people show habitual use, but it’s hard to tell whether it’s a true compulsion. tell whether it’s a true compulsion.

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Arguments Against Caffeine Arguments Against Caffeine Dependence in the DSM:Dependence in the DSM:

Hughes, et al. (1992) Examined previous Hughes, et al. (1992) Examined previous studies and data to question whether any of studies and data to question whether any of the factors warranted their own disorder in the factors warranted their own disorder in DSM-IV.DSM-IV.

Concluded that withdrawal had been well Concluded that withdrawal had been well documented, and should be included (and it documented, and should be included (and it was), but that clinical evidence did not exist to was), but that clinical evidence did not exist to warrant a dependence or abuse diagnoses. warrant a dependence or abuse diagnoses.

Granted that there was evidence to support Granted that there was evidence to support caffeine dependence (some physical or caffeine dependence (some physical or behavioural harm, and can act as own behavioural harm, and can act as own reinforcer).reinforcer).

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Arguments Against Caffeine Arguments Against Caffeine Dependence in the DSM:Dependence in the DSM:

Hughes et al deny, though, that there’s any Hughes et al deny, though, that there’s any clinical significance to caffeine dependence, as clinical significance to caffeine dependence, as it may not cause any distress or disability, or it may not cause any distress or disability, or increase one’s likelihood of death, pain, injury increase one’s likelihood of death, pain, injury or important loss of personal freedom, which or important loss of personal freedom, which are all implied criteria. are all implied criteria.

Nehlig (1999) agrees, arguing that despite the Nehlig (1999) agrees, arguing that despite the data, the relative harm associated with caffeine data, the relative harm associated with caffeine is too low to warrant its being classified as an is too low to warrant its being classified as an actual disorder. actual disorder.

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Evidence Supporting Evidence Supporting Caffeine Dependence:Caffeine Dependence:

Strain, et al. (1994) asserted that caffeine Strain, et al. (1994) asserted that caffeine does demonstrate features typical of a does demonstrate features typical of a psychoactive drug, upon which psychoactive drug, upon which individuals may become dependent.individuals may become dependent.

Used series of case studies:Used series of case studies: Individuals continued drug use despite their Individuals continued drug use despite their

own desires and others’ recommendationsown desires and others’ recommendations Showed evidence of dependence leading to Showed evidence of dependence leading to

dysfunction in their livesdysfunction in their lives

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Strain et al. (1994)Strain et al. (1994)

Subjects reported impairment in the form Subjects reported impairment in the form of screaming at their families, missing of screaming at their families, missing work, making costly mistakes at work, work, making costly mistakes at work, having to leave work, going to bed early, having to leave work, going to bed early, being unable to care for their children, being unable to care for their children, and failing to do household chores, and failing to do household chores, among other things.among other things.

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Evidence in Support of Evidence in Support of Caffeine DependenceCaffeine Dependence

Bernstein et al (2002) examined caffeine Bernstein et al (2002) examined caffeine dependence in teens.dependence in teens.

N=36N=36 Based on interviews, found that 77.8% Based on interviews, found that 77.8%

described withdrawal symptoms, 38.9% described withdrawal symptoms, 38.9% reported desire or unsuccessful attempts to reported desire or unsuccessful attempts to control use, and 16.7% acknowledged control use, and 16.7% acknowledged continuing use despite knowledge of negative continuing use despite knowledge of negative physical/psychological consequences. physical/psychological consequences.

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Evidence in Support of Evidence in Support of Caffeine DependenceCaffeine Dependence

Similarly, Hughes et al (1998) randomly-selected 162 Similarly, Hughes et al (1998) randomly-selected 162 caffeine users, and asked about DSM-IV criteria for caffeine users, and asked about DSM-IV criteria for dependence, abuse, intoxication and withdrawaldependence, abuse, intoxication and withdrawal

Strong desire or unsuccessful attempt to stop use – Strong desire or unsuccessful attempt to stop use – 56%56%

Spending a great deal of time with the drug – 50%Spending a great deal of time with the drug – 50% Using more than intended – 28%Using more than intended – 28% Withdrawal – 24%Withdrawal – 24% Using despite knowledge of harm – 14%Using despite knowledge of harm – 14% Tolerance – 8%Tolerance – 8% Foregoing activities to use – 1%Foregoing activities to use – 1% Intoxication – 7%Intoxication – 7%

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Hughes et al (1998) noted that many of Hughes et al (1998) noted that many of the DSM criteria for dependence/abuse the DSM criteria for dependence/abuse would not readily appear to apply to would not readily appear to apply to caffeine use (e.g., legal problems, great caffeine use (e.g., legal problems, great deal of time spent obtaining the drug, deal of time spent obtaining the drug, drug induced failure to function).drug induced failure to function).

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Benefits of Adding to the Benefits of Adding to the DSM DSM

Some feel that placement in the “not otherwise Some feel that placement in the “not otherwise specified” diagnostic categories is inadequate. specified” diagnostic categories is inadequate.

An increase in coverage should be strived for. An increase in coverage should be strived for. Lowering the ‘threshold’ of the criteria would Lowering the ‘threshold’ of the criteria would result in more sufferers being identified and result in more sufferers being identified and receiving treatment. receiving treatment.

Some argue that the inclusion of new disorders Some argue that the inclusion of new disorders will stimulate research in otherwise obscure will stimulate research in otherwise obscure areas. areas.

(Pincus et al, 1992)(Pincus et al, 1992)

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Costs of Adding to the Costs of Adding to the DSMDSM

Some advocate that inclusion of Some advocate that inclusion of categories that lack extensive empirical categories that lack extensive empirical research trivialize the field. research trivialize the field.

With new categories come ‘false With new categories come ‘false positives’. positives’.

The benefit of precise diagnoses must be The benefit of precise diagnoses must be balanced with the pitfalls of an already balanced with the pitfalls of an already complex system of categorization. complex system of categorization.

(Pincus et al, 1992)(Pincus et al, 1992)

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DiscussionDiscussion

So, do you think Caffeine Dependence So, do you think Caffeine Dependence should be included?should be included?

If a whole society accepts a pattern of If a whole society accepts a pattern of drug use, should it be classified as a drug use, should it be classified as a disorder? It is, after all, “normal”. disorder? It is, after all, “normal”.

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Graduate StudiesGraduate Studies

Dr. John R. Hughes PhD.Dr. John R. Hughes PhD.University of VermontUniversity of VermontInterested in human research on nicotine, addiction, and gradual Interested in human research on nicotine, addiction, and gradual reduction methods. reduction methods.

Dr. Allison Oliveto PhD.Dr. Allison Oliveto PhD.University of Arkansas for Medical SciencesUniversity of Arkansas for Medical SciencesExamines behavioural effects of drugs and dependence.Examines behavioural effects of drugs and dependence.

Dr. Eric Strain M.D.Dr. Eric Strain M.D.John Hopkins UniversityJohn Hopkins UniversityAddiction Psychiatry ServicesAddiction Psychiatry Services

Dr. Keith B.J. Franklin Dr. Keith B.J. Franklin McGill UniversityMcGill UniversityResearches drug dependence, and reinforcement. Researches drug dependence, and reinforcement.

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ReferencesReferences

American Psychiatric Association: American Psychiatric Association: Diagnostic and Statistical Diagnostic and Statistical Manual of Mental Disorders, Manual of Mental Disorders, Fourth Edition, Text Revision. Fourth Edition, Text Revision. Washington, DC, American Psychiatric Association, 2000.Washington, DC, American Psychiatric Association, 2000.

Bernstein, G., Carroll, M., Thuras, P., Cosgrove, K., and Roth, M. Bernstein, G., Carroll, M., Thuras, P., Cosgrove, K., and Roth, M. (2002). Caffeine Dependence in Teenagers. (2002). Caffeine Dependence in Teenagers. Drug and Alcohol Drug and Alcohol Dependence, Dependence, 66, 1-6. 66, 1-6.

Hughes, John R., Oliveto, Alison H., Helzer, John E., Higgins, Hughes, John R., Oliveto, Alison H., Helzer, John E., Higgins, Stephen T., and Bickel, Warren K. (1992). Should caffeine abuse, Stephen T., and Bickel, Warren K. (1992). Should caffeine abuse, dependence, or withdrawl be added to DSM-IV and ICD-10? dependence, or withdrawl be added to DSM-IV and ICD-10? The The American Journal of Psychiatry,American Journal of Psychiatry, 149(1), 33-40. 149(1), 33-40.

Hughes, John R., Oliveto, Allison H., Liguori, Anthony, Carpenter, Hughes, John R., Oliveto, Allison H., Liguori, Anthony, Carpenter, Joseph, and Howard, Timothy. (1998). Endorsement of DSM-IV Joseph, and Howard, Timothy. (1998). Endorsement of DSM-IV dependence criteria among caffeine users. dependence criteria among caffeine users. Drug and Alcohol Drug and Alcohol Dependence,Dependence, 52, 99–107. 52, 99–107.

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ReferencesReferences

Nehlig, A. (1999). Are we dependent upon coffee and Nehlig, A. (1999). Are we dependent upon coffee and caffeine? A review on human and animal data. caffeine? A review on human and animal data. Neuroscience and Biobehavioral Reviews,Neuroscience and Biobehavioral Reviews, 23, 563– 23, 563–576.576.

Pincus, H., Frances, A., Wakefield Davis, W., First, M., Pincus, H., Frances, A., Wakefield Davis, W., First, M., and Widiger, T. (1992). DSM-IV and New Diagnostic and Widiger, T. (1992). DSM-IV and New Diagnostic Criteria: Holding the Line of Proliferation. Criteria: Holding the Line of Proliferation. The American The American Journal of Psychiatry, Journal of Psychiatry, 149(1), 112-117.149(1), 112-117.

Strain, Eric C., Mumford, Geoffrey K., Silverman, Strain, Eric C., Mumford, Geoffrey K., Silverman, Kenneth, and Griffiths, Roland R. (1994). Caffeine Kenneth, and Griffiths, Roland R. (1994). Caffeine Dependence Syndrome. Dependence Syndrome. JAMA, The Journal of the JAMA, The Journal of the American Medical Association, American Medical Association, 272(13), 1043-1048. 272(13), 1043-1048.