Caffeine Intoxication


Caffeine Intoxication & Withdrawal: Growing Public Health Menace

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 16 oz. Coca Colas, so much so that growing attention is turning to both the short-term and long-term serious health effects of high 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, chronic edema
• 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 (Haskell et al., 2005; 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 and medications (Whitsett, 1984). 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. Deleterious effects are noted in high doses of caffeine during interaction with many prescription medications, especially diuretics, antiasthmatics, and antidepressants. 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, PepsiCo, 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 can—coupled with increasingly high sugar diet--translate into behavioral and academic challenges (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-three 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 nearly 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;, 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:

• Chronic mild to moderate dehydration via measurement of Antidiuretic hormone ADH tests, compared to plasma sodium levels.  
• Immunosuppression and/or adrenal insufficiency or depletion via C-reactive and Adrenocorticotropic hormone stimulation (ACTH Stimulation) tests
• Caffeine-triggered allergy or asthmatic response via tests for IgE, IgG, etc.
• 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.