Caffeine-Related Disorders

• Caffeine Intoxication
• Caffeine Withdrawal
• Other Caffeine-Induced Disorders
• Unspecified Caffeine-Related Disorder

PRESENTING
 Caffeine Intoxication

Diagnostic Criteria 305.90

(F15.929)

A. Recent consumption of caffeine (typically a high dose well

in excess of 250 mg).

B. Five (or more) of the following signs or symptoms

developing during caffeine use:
1. Restlessness.
2. Nervousness.
3. Excitement.
4. Insomnia.
5. Flushed face.
6. Muscle twitching.
7. Rambling flow of thought and speech.
8. Tachycardia.
9. Periods of inexhaustibility.
10. Psychomotor agitation.
C. The signs or symptoms in Criterion B cause clinically
significant distress or impairment in social, occupational, or
other important areas of functioning.

D. The signs or symptoms are not attributable to another

medical condition and are not better explained by another
mental disorder.
Associated Features Supporting Diagnosis

Mild sensory disturbances (e.g., ringing in the ears and

flashes of light) may occur with high doses of caffeine.

Although large doses of caffeine can increase heart rate,

smaller doses can slow heart rate.

Whether excess caffeine intake can cause headaches.

On physical examination, agitation, restlessness, sweating,

tachycardia, flushed face, may be seen.
Prevalence

The prevalence of caffeine intoxication in the general

population is unclear.

In the United States, approximately 7% of individuals in

the population may experience five or more symptoms.
Development and Course
Caffeine intoxication symptoms usually remit within the first day.
However, individuals who consume very high doses of caffeine (i.e., 5-
10 g) may require immediate medical attention, as such doses can be
lethal.

With advancing age, individuals are likely to demonstrate increasingly

intense reactions to caffeine, with greater complaints of interference
with sleep or feelings of hyper arousal.

Caffeine intoxication among young individuals, including energy

drinks, has been observed.

Children and adolescents may be at increased risk for caffeine

intoxication because of lack of tolerance, and lack of knowledge about
 Risk and Prognostic Factors

Environmental. Caffeine intoxication is often seen among

individuals who use caffeine less frequently or in those who
have recently increased their caffeine intake by a substantial
amount.

Oral contraceptives significantly decrease the elimination of

caffeine and consequently may increase the risk of
intoxication.
Functional Consequences of Caffeine
Intoxication

Impairment from caffeine intoxication may have serious

consequences, including dysfunction at work or school, or
failure to fulfill role obligations.
Differential Diagnosis

Other mental disorders. Caffeine intoxication may be

characterized by symptoms (e.g., panic attacks) that resemble
primary mental disorders.

To meet criteria for caffeine intoxication, the symptoms must

not be associated with another medical condition or another
mental disorder, such as an anxiety disorder, that could better
explain them.

Manic episodes; panic disorder; generalized anxiety

disorder; sedative, hypnotic, or anxiolytic withdrawal; and
medication-induced side effects (e.g., akathisia).
Other caffeine-induced disorders. Caffeine intoxication is
differentiated from caffeine-induced anxiety disorder, with
onset during intoxication, see "Substance/Medication-
Induced Anxiety Disorder", and caffeine-induced sleep
disorder, with onset during intoxication, see "Substance/
Medication-Induced Sleep Disorder“.

The symptoms in these latter disorders are in excess of those

usually associated with caffeine intoxication.
Comorbidity

Heavy doses of caffeine (e.g., >400 mg) can cause anxiety

and somatic symptoms and distress.

Extremely high doses of caffeine, respiratory failure may

result in death.

Excessive caffeine use is associated with depressive

disorders, bipolar disorders, eating disorders, psychotic
disorders, sleep disorders, and substance-related disorders,
whereas individuals with anxiety disorders are more likely to
avoid caffeine.
 Caffeine Withdrawal

Diagnostic Criteria
292.0(F15.93)

A. Prolonged daily use of caffeine.

B. Abrupt cessation of or reduction in caffeine use, followed

within 24 hours by three (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 symptoms (nausea, vomiting, or muscle pain).
C. The signs or symptoms in Criterion B cause clinically
significant distress or impairment in social, occupational,
or other important areas of functioning.

D. The signs or symptoms are not associated with the

physiological effects of another medical condition (e.g.,
migraine, viral illness) and are not better explained by
another mental disorder.
Associated Features Supporting Diagnosis

Caffeine abstinence has been shown to be associated with

impaired behavioral and cognitive performance (e.g.,
sustained attention).

Caffeine withdrawal symptoms are significantly associated

with increases in theta power and decreases in beta-2 power.
Prevalence

More than 85% of adults and children in the United States

regularly consume caffeine, with adult caffeine consumers
ingesting about 280 mg/day on average.

In the United States, headache may occur in approximately

50% of cases of caffeine abstinence.

In attempts to permanently stop caffeine use, more than 70%

of individuals may experience at least one caffeine
withdrawal symptom (47% may experience headache), and
24% may experience headache plus one or more other
symptoms.
Development and Course

Symptoms usually begin 12–24 hours after the last caffeine

dose and peak after 1–2 days of abstinence.
Caffeine withdrawal symptoms last for 2–9 days, with the
possibility of withdrawal headaches occurring for up to 21
days.
Symptoms usually remit rapidly (within 30–60 minutes) after
re-ingestion of caffeine.
Caffeine is unique in that it is a behaviorally active drug that
is consumed by individuals of nearly all ages. Rates of
caffeine consumption increase with age until the early to mid-
30s.
The use of caffeinated energy drinks is increasing with in
Risk and Prognostic Factors

Temperamental. Heavy caffeine use has been observed

among individuals with mental disorders, including eating
disorders; smokers; drug and alcohol abusers. Thus, these
individuals could be at higher risk for caffeine withdrawal.

Environmental. The unavailability of caffeine is an

environmental risk factor for withdrawal symptoms. While
caffeine is legal and usually widely available, there are
conditions in which caffeine use may be restricted, such as
during medical procedures, pregnancy, hospitalizations,
wartime, and travel. These external environmental
circumstances may precipitate a withdrawal syndrome in
Genetic and physiological factors. Genetic factors appear to
increase caffeine withdrawal, but no specific genes have been
identified.

Course modifiers. Caffeine withdrawal symptoms usually

remit within 30–60 minutes of re exposure to caffeine. Doses
of caffeine significantly less than one’s usual daily dose may
be sufficient to prevent caffeine withdrawal symptoms (e.g.,
consumption of 25 mg by an individual who typically
consumes 300 mg).
Functional Consequences of Caffeine Withdrawal
Disorder

Rates of functional impairment range from 10% to 55%, with

rates as high as 73% found among individuals who also show
other problematic features of caffeine use.

Examples of functional impairment include being unable to

work, exercise, staying in bed all day; missing religious
services; and cancelling a social gathering.

Caffeine withdrawal headaches may be described by

individuals as “the worst headaches” ever experienced.
Differential Diagnosis

Other medical disorders and medical side effects.

Several disorders should be considered in the differential
diagnosis of caffeine withdrawal. Caffeine withdrawal can
migraine and other headache disorders, viral illnesses, sinus
conditions, tension, other drug withdrawal states (e.g., from
cocaine), and medication side effects.
The final determination of caffeine withdrawal should rest
the particular clinical features presented by the individual.
Comorbidity

Caffeine withdrawal may be associated with major

depressive disorder, generalized anxiety disorder, panic
disorder, antisocial personality disorder in adults, moderate
to severe alcohol use disorder, and cannabis and cocaine use.
 Other Caffeine-Induced Disorders

The following caffeine-induced disorders are described in

other chapters of the manual with disorders with which they
share phenomenology (see the substance/medication- induced
mental disorders in these chapters): caffeine-induced anxiety
disorder (“Anxiety Disorders”) and caffeine-induced sleep
disorder (“Sleep-Wake Disorders”). These caffeine-induced
disorders are diagnosed instead of caffeine intoxication or
caffeine withdrawal only when the symptoms are sufficiently
severe to warrant independent clinical attention.
Unspecified Caffeine-Related Disorder
292.9 (F15.99)

This category applies to presentations in which symptoms

characteristic of a caffeine- related disorder that cause
clinically significant distress or impairment in social,
occupational, or other important areas of functioning
predominate but do not meet the full criteria for any specific
caffeine-related disorder or any of the disorders in the
substance-related and addictive disorders diagnostic class.