Are we addicted to coffee?

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Are we addicted to coffee?

• The (Possible) Necessity of Caffeine Dependence
  Syndrome in the DSM
• Amanda Smallwood
• 100067083

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Caffeine Background

• Average Americans 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 wouldnt 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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Caffeines 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).

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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.

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Clinical Dependence, as Well?

• Patterns of consumption
• Many feel its 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 its hard to
  tell whether its 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 theres any
  clinical significance to caffeine dependence, as
  it may not cause any distress or disability, or
  increase ones 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.
• N36
• 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

• 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, 99107.

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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,
  563576.
• 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.