Deborah Brauser

December 15, 2011

December 15, 2011 (Scottsdale, Arizona) — Caffeine withdrawal syndrome is being recommended for inclusion in the "main" section of the upcoming Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), report work group members.

This issue, along with several others, was discussed during a presentation on potential changes to the substance use disorders chapter of the DSM-5 at the American Academy of Addiction Psychiatry (AAAP) 22nd Annual Meeting & Symposium.

DSM-5 work group member Alan J. Budney, PhD, noted that caffeine is everywhere. Not only can it be found in soft drinks, coffee, energy drinks, alcohol, and chocolates; he noted that it can also be found in some women's vitamins and even snacks such as "caffeinated peanuts."

"Caffeine is invading our society more and more. So there's concern enough to consider this topic seriously, even though it's probably one of the more controversial issues faced by our work group," Dr. Budney, who is also a clinical psychologist and professor of psychiatry at the University of Arkansas for Medical Sciences in Little Rock, told Medscape Medical News.

"We feel that there is enough data to support a caffeine withdrawal syndrome. There are enough people who go into withdrawal — that if they don't get caffeine, it becomes a real syndrome and can affect work, sleep, or whatever they need to do. So we're suggesting that it 'make the big leagues' and become part of the DSM to make sure everyone is aware of it."

Other issues discussed (sometimes excitedly) among participants at the presentation included proposed name changes for both the chapter and the overall disorders grouping, adding in "disordered gambling," and changing disorder severity measurements.

"It's an evolving process and we welcome consultation about these issues and about the manual overall," said Wilson M. Compton, MD, MPE, substance use disorders work group member and from the National Institute on Drug Abuse (NIDA), during the presentation.

Print and electronic versions of the DSM-5 are scheduled for publication in time for the American Psychiatric Association's Annual Meeting in 2013.

Clinical Distress

In a recent report from the US Substance Abuse and Mental Health Services Administration (SAMHSA), and as reported by Medscape Medical News, the number of emergency department visits associated with energy drinks is surging.

"Energy drinks used in excess or in combination with alcohol or drugs can pose a serious health risk, SAMHSA administrator Pamela Hyde said in a press release at the time.

Medscape Medical News also reported on a recent study published in Injury Prevention suggesting that increased consumption of carbonated soft drinks with caffeine may be linked to violent behavior in teenagers.

There have also been numerous studies on caffeine withdrawal, including a literature review published in Psychopharmacology in 2004, which concluded that caffeine-withdrawal syndrome "has been well characterized and there is sufficient empirical evidence to warrant inclusion" in the DSM and in the International Classification of Diseases, Tenth Revision (ICD-10).

Although caffeine withdrawal is currently not included in the DSM-4 as a disorder, it is included in the manual as a "research diagnosis." It also currently appears in the ICD-10.

Dr. Budney said that his work group's recommendation is to now include this syndrome in the "main part" of the substance use disorders chapter of the DSM-5. Proposed criteria include 3 or more of the following symptoms within 24 hours of abrupt cessation or reduction:

  • headache;

  • marked fatigue or drowsiness;

  • dysphoric or depressed mood, or irritability;

  • difficulty concentrating; or

  • nausea, vomiting, or muscle pain/stiffness.

"These need to result in clinically significant distress or impairment. In the past, headache has been the hallmark for this syndrome, but it shouldn't stand alone," said Dr. Budney.

"Also, if someone comes into a hospital with a pretty severe headache or irritability or problems focusing on what they need to, and caffeine isn't available for them, it can be a little scary if they don't know why they're feeling that way. Clinicians should be aware that that's what is happening."

He added that there is "biological plausibility" for this disorder, which has been suggested from neural, behavioral, and genetic data. However, prevalence data are limited.

Ambivalent Issue

During his talk, Dr. Budney also presented results from a survey he created and collected from colleagues in various psychiatric organizations, including the AAAP (overall, n = 500; respondents from the AAAP, n = 123).

He found that the majority of respondents agreed that caffeine withdrawal exists, but the majority were also "not sure" when asked whether it should be included in the DSM-5. The majority of just the AAAP respondents, on the other hand, answered the inclusion question with "most definitely."

"This is a very ambivalent issue and the survey means we need to learn more about this topic," said Dr. Budney.

"Is there a clinical need? Will it potentially cause harm to include it in the DSM? And is there a treatment for it? These are things we need to explore further. But we also feel there's enough data to recommend putting it into section 3 of the manual as a disorder just like withdrawal of alcohol, tobacco, cocaine, etc."

Dr. Budney also noted that the workgroup is recommending that caffeine use disorder or "caffeine dependence syndrome," which is already listed in the ICD-10, should not be included in the DSM-5.

"Even though a lot of people take in caffeine every day and may be considered 'dependent' on it — that they would have at least mild symptoms if they stopped taking it — I don't think most actually have caffeine use disorder. Nobody's done enough research in a large enough population to really determine how many people really do suffer from this or are trying to quit and can't," he said.

"The bottom line is there isn't enough data yet and we weren't comfortable putting caffeine dependence in the manual as a major disorder. And there was a little worry that including it might minimize other types of abuse disorders."

Terminology Changes?

Dr. Compton reported during the same symposium that the terminology work group subcommittee is proposing name changes for primary substance disorders and for the overall chapter in the DSM-5 that deals with the disorders.

The chapter heading in the DSM-4 reads "Substance Use Disorders/Substance Related Disorders," and disorders themselves include the term "abuse" or "dependence."

"We wanted to eliminate abuse/dependence in favor of a unified set of criteria," said Dr. Compton. He also noted that past research has suggested that "abuse" is more stigmatizing than the term "use disorder."

Although the subcommittee is currently recommending the new chapter heading "Substance, Gambling and Related Disorders," it is also considering "Substance Use Disorders, Addictions, and Related Disorders."

"That is still the subject of debate among the task force right now. However, the disorder headings are pretty much set now," reported Dr. Compton.

They are proposing that those headings now use the term "disorder," as in "alcohol use disorder," "amphetamine use disorder," and so forth.

Meeting participants shared several concerns about these changes, including that many professional societies freely use the term "addiction."

"Have you thought about what you're going to say in the narrative that goes in the chapter about the incredible awkwardness of having a big statistical and diagnostic manual that lines up with the ICD with the heading of "substance use disorders" — yet this very organization includes "addiction" in its name and its journal is called Addiction?" asked Michael Miller, MD, medical director at Herrington Recovery Center at Rogers Memorial Hospital in Oconomowoc, Wisconsin, and past president of the American Society of Addiction Medicine.

"Are you going to deal with this or just let it lie?" he laughed, as the audience clapped in response.

Dr. Compton answered that he hopes that will be dealt with in the chapter's introduction section.

Other Proposed Changes

Other proposed changes for the DSM-5 reported during the same symposium included adding cannabis withdrawal into the substance use disorders chapter, increasing tobacco disorder criteria, adding in craving and removing "legal problems" criteria, and modifying overall remission specifiers.

Also, "fetal alcohol syndrome is under consideration for inclusion and internet use disorders (and perhaps other behavioral addictions) are identified as conditions in need of further study," the work group reports.

"Substance induced mental illnesses will be placed primarily in relevant mental illness chapters, with appropriate cross-referencing," they add.

Another issue that garnered a lot of debate from the meeting participants surrounded the proposed changes to severity measurements.

"Two severity approaches are envisioned — one for case severity that tallies diagnostic criteria and a second that measures substance use frequency," they write.

"We didn't start this process from scratch. We started with the DSM-4 and wanted to move forward from it based on evidence. It was never our intention to throw out all of the old stuff," said Dr. Compton.

"With that said, nothing is final until the manual is published."

Information on current DSM-5 recommendations can be found on its Web site.

American Academy of Addiction Psychiatry (AAAP) 22nd Annual Meeting and Symposium: Workshop B2. Presented December 9, 2011.

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