Download Are we addicted to coffee?

Are we addicted to
coffee?
The (Possible) Necessity of Caffeine
Dependence Syndrome in the DSM
Amanda Smallwood
100067083
1
Caffeine Background
 Average American’s caffeine intake is 200 mg/day, and
up to 30% of Americans consume 500 mg or more per
day.
 Coffee, brewed = 100-140 mg/8oz.
 Coffee, instant = 65-100 mg/8oz.
 Tea = 40-100 mg/8oz.
 Caffeinated soda = 45 mg/12oz.
 Over-the-counter cold remedies = 25-50 mg/tablet
 Antidrowsiness pills = 100-200 mg/tablet
 Weight-loss aids = 75-200 mg/tablet
 Chocolate = 5 mg/chocolate bar
 (DSM-IV, pg 231)
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What is an addiction?
 Some argue that addictive drugs
engender “compulsion” or overwhelming
involvement that takes over all life activity
to the exclusion of other interests. (so
caffeine wouldn’t qualify)
 Others say the substance has to have
reinforcing effects, and produce harmful
effects on the user and the society. (so,
maybe)
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Substance-Related
Disorders
 Substance Use Disorders
 Substance Dependence
 Substance Abuse
 Substance-Induced Disorders





Substance Intoxication
Substance Withdrawal
Substance-Induced Delirium
Substance-Induced Mood Disorder
Substance-Induced Sexual Dysfunction…..
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What is Substance
Dependence?

“A maladaptive pattern of substance use, leading to clinically significant
impairment or distress, as manifested by 3 or more of the following,
occuring at any time in the same 12-month period:
 1) Tolerance, as defined by either a need for markedly increased amounts of
the substance to achieve intoxication or desired effect, or markedly diminished
effect with continued use of the same amount of the substance
 2) Withdrawal
 3) the substance is often taken in larger amounts or over a longer period of
time than was intended
 4) there is a persistent desire or unsuccessful efforts to cut down or control
substance use
 5) a great deal of time is spent in activities necessary to obtain the substance,
use the substance, or recover from its effects
 6) important social, occupational, or recreational activities are given up or
reduced because of substance use
 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
or exaccerbated by the substance “
(DSM-IV 197)
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What is Substance
dependence?
 Specifiers:
 With Physiological Dependence
 Tolerance (“need for greater amounts of substance
to achieve desired effect”)
 Withdrawal (“maladaptive behavioural change, with
physiological and cognitive concomitants, that
occurs when blood or tissue concentrations of a
substance decline in an individual who had
maintained prolonged heavy use of the substance”
DSM-IV pp194)
 Without Physiological Dependence
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What is Substance Abuse?
 “A maladaptive pattern of substance use
leading to clinically significant impairment or
distress as manifested by one or more of the
following, occurring within a 12-month period:
 1) recurrent substance use resulting in a failure to
fulfill major role obligations at work, school, or home
 2) recurrent substance use in situations in which it is
physically hazardous
 3) recurrent substance-related legal problems
 4) continued substance use despite having
persistent or recurrent social or interpersonal
problems caused or exacerbated by the effects of
the substance
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Current DSM-IV Diagnoses
 Caffeine Withdrawal Syndrome
 Caffeine Intoxication
 Other Caffeine-Induced Disorders (diagnosed
when symptoms exceed those usually associated
with Caffeine Intoxication)
 Caffeine-Induced Anxiety Disorder
 Caffeine-Induced Sleep Disorder
 Acute doses exceeding 10g (approx. 100 cups of
coffee) can result in grand mal seizures and
respiratory failure which may result in death.
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Caffeine’s Properties of
Physical Dependence
 Acts as reinforcer (leads to a release of dopamine in
the prefrontal cortex, Nehlig, 1999)
 Hughes et al (1992) found that some coffee and soda
drinkers reliably self-administered caffeinated
beverages in preference to decaffeinated in a doubleblind test.
 Tolerance to some subjective effects of caffeine seems
to occur, but complete tolerance to many effects of
caffeine on the central nervous system is rarely seen
(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.
10
Clinical Dependence, as
Well?
 Patterns of consumption
 Many feel it’s the same syndrome but milder
than heroin or cocaine.
 But, since effects are less pronounced, it
cannot be equated with other drugs of
dependence.
 Many people show habitual use, but it’s hard to
tell whether it’s a true compulsion.
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Arguments Against Caffeine
Dependence in the DSM:
 Hughes, et al. (1992) Examined previous
studies and data to question whether any of
the factors warranted their own disorder in
DSM-IV.
 Concluded that withdrawal had been well
documented, and should be included (and it
was), but that clinical evidence did not exist to
warrant a dependence or abuse diagnoses.
 Granted that there was evidence to support
caffeine dependence (some physical or
behavioural harm, and can act as own
reinforcer).
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Arguments Against Caffeine
Dependence in the DSM:
 Hughes et al deny, though, that there’s any
clinical significance to caffeine dependence, as
it may not cause any distress or disability, or
increase one’s likelihood of death, pain, injury
or important loss of personal freedom, which
are all implied criteria.
 Nehlig (1999) agrees, arguing that despite the
data, the relative harm associated with caffeine
is too low to warrant its being classified as an
actual disorder.
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Evidence Supporting
Caffeine Dependence:
 Strain, et al. (1994) asserted that caffeine
does demonstrate features typical of a
psychoactive drug, upon which
individuals may become dependent.
 Used series of case studies:
 Individuals continued drug use despite their
own desires and others’ recommendations
 Showed evidence of dependence leading to
dysfunction in their lives
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Strain et al. (1994)
 Subjects reported impairment in the form
of screaming at their families, missing
work, making costly mistakes at work,
having to leave work, going to bed early,
being unable to care for their children,
and failing to do household chores,
among other things.
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Evidence in Support of
Caffeine Dependence
 Bernstein et al (2002) examined caffeine
dependence in teens.
 N=36
 Based on interviews, found that 77.8%
described withdrawal symptoms, 38.9%
reported desire or unsuccessful attempts to
control use, and 16.7% acknowledged
continuing use despite knowledge of negative
physical/psychological consequences.
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Evidence in Support of
Caffeine Dependence
 Similarly, Hughes et al (1998) randomly-selected 162
caffeine users, and asked about DSM-IV criteria for
dependence, abuse, intoxication and withdrawal
 Strong desire or unsuccessful attempt to stop use –
56%
 Spending a great deal of time with the drug – 50%
 Using more than intended – 28%
 Withdrawal – 24%
 Using despite knowledge of harm – 14%
 Tolerance – 8%
 Foregoing activities to use – 1%
 Intoxication – 7%
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 Hughes et al (1998) noted that many of
the DSM criteria for dependence/abuse
would not readily appear to apply to
caffeine use (e.g., legal problems, great
deal of time spent obtaining the drug,
drug induced failure to function).
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Benefits of Adding to the
DSM
 Some feel that placement in the “not otherwise
specified” diagnostic categories is inadequate.
 An increase in coverage should be strived for.
Lowering the ‘threshold’ of the criteria would
result in more sufferers being identified and
receiving treatment.
 Some argue that the inclusion of new disorders
will stimulate research in otherwise obscure
areas.
 (Pincus et al, 1992)
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Costs of Adding to the
DSM
 Some advocate that inclusion of
categories that lack extensive empirical
research trivialize the field.
 With new categories come ‘false
positives’.
 The benefit of precise diagnoses must be
balanced with the pitfalls of an already
complex system of categorization.
 (Pincus et al, 1992)
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Discussion
 So, do you think Caffeine Dependence
should be included?
 If a whole society accepts a pattern of
drug use, should it be classified as a
disorder? It is, after all, “normal”.
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Graduate Studies


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Dr. John R. Hughes PhD.
University of Vermont
Interested in human research on nicotine, addiction, and gradual
reduction methods.
Dr. Allison Oliveto PhD.
University of Arkansas for Medical Sciences
Examines behavioural effects of drugs and dependence.
Dr. Eric Strain M.D.
John Hopkins University
Addiction Psychiatry Services
Dr. Keith B.J. Franklin
McGill University
Researches drug dependence, and reinforcement.
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References
 American Psychiatric Association: Diagnostic and Statistical
Manual of Mental Disorders, Fourth Edition, Text Revision.
Washington, DC, American Psychiatric Association, 2000.
 Bernstein, G., Carroll, M., Thuras, P., Cosgrove, K., and Roth, M.
(2002). Caffeine Dependence in Teenagers. Drug and Alcohol
Dependence, 66, 1-6.
 Hughes, John R., Oliveto, Alison H., Helzer, John E., Higgins,
Stephen T., and Bickel, Warren K. (1992). Should caffeine abuse,
dependence, or withdrawl be added to DSM-IV and ICD-10? The
American Journal of Psychiatry, 149(1), 33-40.
 Hughes, John R., Oliveto, Allison H., Liguori, Anthony, Carpenter,
Joseph, and Howard, Timothy. (1998). Endorsement of DSM-IV
dependence criteria among caffeine users. Drug and Alcohol
Dependence, 52, 99–107.
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References
 Nehlig, A. (1999). Are we dependent upon coffee and
caffeine? A review on human and animal data.
Neuroscience and Biobehavioral Reviews, 23, 563–
576.
 Pincus, H., Frances, A., Wakefield Davis, W., First, M.,
and Widiger, T. (1992). DSM-IV and New Diagnostic
Criteria: Holding the Line of Proliferation. The American
Journal of Psychiatry, 149(1), 112-117.
 Strain, Eric C., Mumford, Geoffrey K., Silverman,
Kenneth, and Griffiths, Roland R. (1994). Caffeine
Dependence Syndrome. JAMA, The Journal of the
American Medical Association, 272(13), 1043-1048.
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