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1 Are we addicted to coffee? The (Possible) Necessity of Caffeine Dependence Syndrome in the DSM Amanda Smallwood 100067083.

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Presentation on theme: "1 Are we addicted to coffee? The (Possible) Necessity of Caffeine Dependence Syndrome in the DSM Amanda Smallwood 100067083."— Presentation transcript:

1 1 Are we addicted to coffee? The (Possible) Necessity of Caffeine Dependence Syndrome in the DSM Amanda Smallwood

2 2 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 = mg/8oz.  Coffee, instant = mg/8oz.  Tea = mg/8oz.  Caffeinated soda = 45 mg/12oz.  Over-the-counter cold remedies = mg/tablet  Antidrowsiness pills = mg/tablet  Weight-loss aids = mg/tablet  Chocolate = 5 mg/chocolate bar  (DSM-IV, pg 231)

3 3 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)

4 4 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…..

5 5 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)

6 6 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

7 7 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

8 8 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.

9 9 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 double- blind 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).

10 10   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.

11 11 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.

12 12 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).

13 13 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.

14 14 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

15 15 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.

16 16 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.

17 17 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%

18 18  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).

19 19 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)

20 20 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)

21 21 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”.

22 22 Graduate Studies  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.

23 23 References  American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC, American Psychiatric Association,  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),  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.

24 24 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),  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),


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