An Overlooked Withdrawal Syndrome?

An APA Poster Brief

Bret S. Stetka, MD; Ali Canton, MD

Disclosures

June 13, 2013

Editor's Note: While onsite at the 2013 Annual Meeting of the American Psychiatric Association, Medscape spoke with Ali Canton, MD, of the University of Oklahoma College of Medicine about the significance of caffeine withdrawal.

Medscape: Hi, Dr. Canton. Can you summarize your study looking at caffeine withdrawal?

Dr. Canton: Essentially, this a literature review looking at caffeine withdrawal.[1] This is based on research that supported the inclusion of the diagnostic criteria in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5).Withdrawal from caffeine can cause a noticeable level of impairment as well as make the formulation of a mental illness diagnosis difficult. For example, it can look like mild depression, particularly depression with somatic symptoms.

I think we should be aware of the significance of caffeine withdrawal, especially when we see patients with symptoms that are seen in caffeine withdrawal, such as headache and fatigue. Caffeine withdrawal does not compare in severity to withdrawal from other substances, but it can potentially impair an individual's level of functioning.

Medscape: Including caffeine withdrawal in DSM-5 was somewhat controversial. On the basis of existing data, does it deserve to be in the manual?

Dr. Canton: From what I've read, I believe it does, in part because it's so prevalent. The new criteria will hopefully make doctors more aware of it. I definitely think it's the most common withdrawal condition, because caffeine is just so commonly used.

DSM-V Criteria for Caffeine Withdrawal[2]

A. Prolonged daily use of caffeine.

B. Abrupt cessation of caffeine use, or reduction in the amount of caffeine used, followed within 24 hours by 3 or more of the following symptoms:

     (1) Headache

     (2) Marked fatigue or drowsiness

     (3) Dysphoric mood, depressed mood, or irritability

     (4) Difficulty concentrating

     (5) Flu-like somatic symptoms, nausea, vomiting, or muscle pain/stiffness

C. The symptoms in criterion B cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

D. The symptoms are not due to the direct physiologic effects of a general medical condition (eg, migraine, viral illness) and are not better accounted for by another mental disorder.

Medscape: Are psychiatrists treating caffeine withdrawal at this point?

Dr. Canton: Psychiatrists are aware that it could be there and be responsible for certain symptoms, but on average we are not screening for it in our patient histories -- in the inpatient setting in particular. The caffeine content of various beverages is not common knowledge. Fortunately, beverage companies have added caffeine content on their labels within the past few years. Also, the majority of inpatient psychiatric units don't allow caffeine use owing to concerns of its stimulant effects on behavior and sleep. Prophylactic treatment might be warranted for individuals at risk for impairing caffeine-withdrawal syndromes: history of withdrawal and increased tolerance to a significant amount of caffeine, such as 3 cups of coffee.

Medscape: Which beverages have the most caffeine, and have you seen an increase in caffeine withdrawal with the popularity of caffeinated energy drinks?

Dr. Canton: Yes, energy drinks are definitely showing up more and more. 5-Hour Energy Drink, which comes in 1.9-fluid ounce bottles, has 208 milligrams of caffeine, which is almost equivalent to a small 12-ounce Starbucks coffee. And keep in mind that the longer you brew coffee, or let it sit, the more caffeine it has. If you see old coffee sitting there at work, it probably has more caffeine in it. The same goes for tea.

Medscape: What does your study imply in terms of treating caffeine withdrawal?

Dr. Canton: On the basis of my reading, clinicians should consider tapering off 25% every 2 days. But even just 15-25 mg twice per day, upon awakening and the early afternoon, can help with some of the symptoms. And because inpatient psychiatric units prefer to avoid caffeine tapers that start with dosages approaching an individual's daily consumption, 200-500 mg, even just that small dose can be beneficial.

Suggested Reading

Juliano LM. Griffiths RR. A critical review of caffeine withdrawal: empirical validation of symptoms and signs, incidence, severity, and associated features. Psychopharmacology (Berl). 2004;176:1-29.

Evans SM, Griffiths RR. Caffeine withdrawal: a parametric analysis of caffeine dosing conditions. J Pharmacol Exp Ther. 1999;289:285-294.

American Psychiatric Association. DSM5 development. R 24 caffeine withdrawal. April 21, 2011. http://www.dsm5.org/ProposedRevision/Pages/proposedrevision.aspx?rid=553# Accessed February 9, 2012.

Center for Science in the Public Interest. Caffeine content of food & drugs. December 2012. http://www.cspinet.org/new/cafchart.htm Accessed May 1, 2013.

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