Psychiatrist, Purdysburn Hospital Belfast, Northern Ireland SUMMARY

Patterns of everyday routine may change even in those cultures considered more resistant to change than others. One such example is that of increasing coffee drinking in the British Isles, with concomitant higher risk of caffeinism. It may be happening in other countries also. A case history is presented of a young woman taking in excess of 20 cups of coffee daily producing an anxiety syndrome which responded to stopping the excessive intake, and combating the withdrawal symptoms. Then, confronted with a patient in an acute anxiety state without adequate reason, but with a previously stable personality, a doctor may continue psychotherapy and be tempted to use anxiolytic drugs, hoping that the anxiety will disappear and not become chronic. Attention has been drawn to the anxiety-type effects of a large intake of caffeine by publications in 19744 and 19752. Coffee consumption in the British Isles is rising and generally it is not the decaffeinated variety used in some other countries. This report is to alert doctors to the possibility of a caffeine-induced state and to prevent the ill-advised use of tranquillisers and production of a prolonged anxiety syndrome as a result. CASE REPORT

early October 1976 a 28 year-old-housewife in a professional family suddenly developed palpitations and panic one evening, followed by persistent anxiety, fluctuating in intensity, with somatic aspects including attacks of cold sweat, shortness of breath and at times tingling in the extremities. She occasionally felt she was losing control over the movements of her limbs and was distressed by a floating sensation. Coming from a stable background both in family and personal history, she had coped confidently with problems in her life. She had learned to live with the troubled Ulster situation, and her marriage was happy and her past health excellent. A comprehensive psychiatric analysis and examination led me to believe, moreover, that I was not dealing with anxiety as the presenting symptom of a depressive or other psychiatric illness. Her family doctor had had her on a regimen In

of benzodiazepines for the six or seven weeks before I saw her. Being uneasy at not finding a definite reason for the onset of her severe disabling symptoms, I suggested that she prepare a timetable to present to me at the next outpatient clinic, showing peak periods of symptoms. I hoped thereby to find precipitating factors. When I mentioned allergy to foodstuffs as a possibility, she queried whether her high coffee consumption might be a factor. In fact, she had been drinking at least 20 cups of strong ground-bean coffee a day for the previous four to six months. On the evening on which the syndrome started, she had brewed coffee continually, while awaiting the return of her sportsman-husband from a distant match - this in itself was not unusual, but the amount of coffee taken had been excessive, even by her own standards. Her coffee intake was promptly stopped, and in an attempt to minimize withdrawal effects of the ’let down’ type, the a of Manitoba Libraries on June 21, halved and was blocking agent added. benzodiazepine dosage Downloaded from isp.sagepub.com at Universitybeta-adrenergic 2015

210 At the same time she was warned about possible withdrawal effects. Ten days later her panic had disappeared, but she was feeling tired and restless, with occasional headaches and dizziness. She was, however, determined to persist, despite feeling uneasy. Three weeks later she was without symptoms, apart from a mild ’deflated feeling’, and all drugs were stopped, except for a mild hypnotic, which she required for a further two weeks. COMMENT

Greden4 (1974) drew attention to the diagnostic possibility of an anxiety state produced by caffeinism in the USA, and this has been commented upon in a leading article in the BMJ2 (1975). Coffee drinking has become, since the war, increasingly popular in many countries, but some people have taken the precaution of using the decaffeinated variety. The Goodman and Gilman textbook, The Pharmacological Basis off Therapeutics (4th Ed. 1970)3 draws attention to the fact that caffeine is a powerful CNS stimulant, and acting on the mycardium directly, ’arrhythmias being encountered in persons who use caffeine beverages to excess’. The fatal oral dose of caffeine in man is about 10 g, but untoward reactions are not infrequently observed following 1 g, and doses as low as 250 mg are sufficient in some individuals to produce excess irritability, muscular twitching, etc. The average cup of coffee contains 100 - 150 mg of caffeine. The daily intake of this patient had been at least 2 g per day and possibly up to 3 g, well in excess of the levels at which toxicity occurs. She was taking twice the amount recorded for any of the patients in Greden’s paper in 1974. How frequently is this agent thought of as causing symptoms? There are special groups at risk, such as students working for examinations and relatives of moribund patients. A survey of recent British papers on anxiety states reveals no knowledge by their authors of the existence of this syndrome. Ballingerl (1974), however, demonstrated that self-medication was significantly higher in patients taking 10 or more cups of tea or coffee daily than in those taking fewer than 10 cups per day, but he did not specify the psychiatric symptoms. Marley6 (1960), in a paper on the response to some stimulant and depressive drugs of the central nervous system, quoted Locket5 (1957) regarding tremor in persons seen in poisoning with the caffeine-xanthine group of stimulants, but did not comment on it further. At the present time it is quite likely that some patients are receiving anxiolytic drugs which are not only useless in this condition, but may unnecessarily prolong a curable condition. The doctor can learn of its existence by simply asking a few questions.


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Ballinger, B. R.: ’Self-medication in psychiatric patients’ The International Journal of Social Psychiatry 1974 20/3/4 180-185. British Medical Journal. ’Leading Article.’ 1975. I 296-297. Goodman, L. S. & Gilman, A.: The Pharmacological Basis of Therapeutics, 4th edn. New York, Macmillan, 1970. 359-368. Greden, J. F.: ’Anxiety or Caffeinism: A Diagnostic Dilemma’. American Journal of Psychiatry, 1974. 131, 1089-1092. Locket, S.: Clinical Toxicology, London, Kimpton, 1957b, 341. Marley, E.: ’Response to some stimulant and depressant drugs of the central nervous Downloaded fromScience, isp.sagepub.com at University Manitoba Libraries on June 21, 2015 106,of76-92. system.’ Journal of Mental 1960,

Excess coffee and anxiety states.

209 EXCESS COFFEE AND ANXIETY STATES W. A. GORDON MacCALLUM M.B., F.R.C.P.I., F.R.C.PSYCH., D.P.M. Consultant Psychiatrist, Purdysburn Hospital Be...
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