Caffeine Withdrawal Now a Mental Disorder

While many of us thought that paying $5 for a tasty herbal beverage was the real mental disorder, we’ll have to wait for the next psychiatric manual for that diagnosis because a new one is on the table.

If you are a committed coffee drinker or enjoy a few too many caffeinated sodas or drinks on the weekends and are considering modifying your habits, your morning routine and entire world as you know it now has new implications. You may be crazy.

The DSM-V (American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders version five) has a quirky new diagnosis that may affect you. It is called withdrawal from caffeine intoxication. The diagnosis is well meaning. People who consume 250 mg of caffeine can experience caffeine intoxication and can fundamentally change their brain chemistry and the withdrawal period of this drug, yes drug, is now a listed and recognized diagnostic mental disorder. How much is 250 mg?

·      12 ounces (Tall) Starbucks Coffee            

·      32-56 ounces of green tea, brewed for 3 minutes            

·      100 ounces of most sodas (5 – 20 ounce bottles)

·      1.5-16 ounce cans of most energy drinks

·      1.9 ounces of 5-Hour Energy (contains about 208 mg)

Caffeine-related disorders include intoxication which first made it into the DSM-IV in 2011 with symptoms of restlessness, nervousness, excitement, insomnia, flushed face, excessive urination (diuresis), gastrointestinal disturbance, muscle twitching, rambling flow of thought and speech, tachycardia or cardiac arrhythmia, periods of inexhaustibility or unintentional motion (psychomotor agitation).

Caffeine withdrawal and its inclusion as a mental disorder started rumbling almost 10 years ago when an article appeared in Psychopharmacology where researchers from American University (Washington, DC a bastion of caffeine consumption) wrote about the symptoms of withdrawal including

·       Headache

·       Fatigue

·       Decreased energy/activeness

·       Decreased alertness

·       Drowsiness

·       Decreased contentedness

·       Depressed mood

·       Difficulty concentrating

·       Irritability

·       Foggy/not clearheaded

·       Flu-like symptoms

·       Nausea/vomiting

·       Muscle pain/stiffness

With a list of symptoms like this, I’m starting to believe this should be included in the manual. They go on to say “the incidence of headache was 50% and the incidence of clinically significant distress or functional impairment was 13%.” Those are high numbers for withdrawal from a widely available, freely distributed, and highly utilized drug.  

During the first few days of withdrawal, those who drop caffeine cold turkey display all of the tell-tale signs of an addict. They often search for every version of “coffee-methadone” they can find. Yes, the symptoms are transient, but they are intense. Headache and irritability top the symptom list.

What is interesting to me is that they noted that these symptoms of caffeine withdrawal tend to occur 12-24 hours after the high and continue for 2-9 days.

And this may come as no shock, but the higher the daily dose of caffeine, the worse the symptoms. What I found really curious is that symptoms were caused by doses as low as 100 mg. They concluded, mind you, this is 2004, “The caffeine-withdrawal syndrome has been well characterized and there is sufficient empirical evidence to warrant inclusion of caffeine withdrawal as a disorder in the DSM and revision of diagnostic criteria in the ICD.” It is 2013 and now it is included. So instead of being shocked, maybe we should be appalled at how long this inclusion took!

There is a take home point. For those who are embarking upon a new detoxification program, a new health habit, or simply shifting your gears in relation to the food, supplements, or medications you are using, please remember that it is not always the addition of a substance that causes symptoms, but it can also be the removal of substances that causes symptoms (or improvements). So, don’t just tell your healthcare practitioner what you started to fix your problem, but also tell them what you stopped. 

Reference: Juliano LM, Griffiths RR. A critical review of caffeine withdrawal: empirical validation of symptoms and signs, incidence, severity, and associated features. Psychopharmacology (Berl). 2004 Oct;176(1):1-29. Epub 2004 Sep 21.

Updated evidence on menopause hormone therapy

A recent panel has re-evaluated the scientific literature since  the 2001 publication of the Women’s Health Initiative in order to determine if hormone replacement therapy is safe long term and for chronic conditions such as bone loss, cardiovascular risk, and / or mood health. The results of this panel are from critical review of 51 published articles and will guide the standard of care for postmenopausal women. Frankly, we’ve learned a lot in the last 11 years and I think this panel did an excellent job of culling the data albeit falling short of offering reasonable and safe solutions to the challenge of increased risk of chronic disease beginning at menopause. But that's okay. It wasn't their goal. 

http://health.usnews.com/health-news/news/articles/2012/05/28/hrt-update-therapy-may-reduce-fractures-boost-some-risks

In full disclosure, I’m an advocate of natural products so my first inclination is the cheer the panel’s recommendation. It has been my read of the last decade of literature as well. However, it is oversimplified to come to the conclusion that HRT is good or HRT is bad. That binary way of thinking is ruinous. I strongly believe there is a definite place for Hormone Replacement Therapy. I also believe it cannot be used as the panacea it once was thought to be. In the case of bone health, we must be ever mindful of the complete physiology. Sure, estrogen inhibits osteoclastic activity and helps to maintain bone mineral density, but other hormones have a role in osteoblastic activity such as progesterone and testosterone. Growth hormone and cortisol have their own effects partially independent of sex hormones and partially dependent on their levels.  Furthermore, we now have evidence that bone morphogenetic proteins, progenitor cells for bone, have cross talk with estrogen and there may be other unknown interactions to other hormones and signals. Some authorities now place osteopenia and osteoporosis, especially precocious bone loss in the inflammatory disease marker, causing us to work through the contribution of cytokines and prostaglandins whose pathways are influenced by estrogen levels. And this is just bone health, not to mention cardiovascular health and other quality of life issues that are also influenced by hormone status. Why is this important to say? Because, we haven’t heard the last of HRT. We will likely come to understand a further undeclared subpopulation that has little to no risk of cancer and cardiovascular incident. However, we aren’t there yet and we have patients in front of us that need our help. This panel’s recommendation brings us one step closer to the truth. What is missing from the conversation and really outside the scope of this article is the reason for hormone imbalance and potential less risky recommendations that clinicians can make today to support not only the symptoms of menopause but also the long term consequences of hormone loss. Personally, I’ve been involved in understanding this exact mode of action. That is, improving the function of what has become known as the HPA or hypothalamus-pituitary-adrenal axis. In fact, there are several axes that we should be aware of that are influenced by an aging hypothalamus. These axes, but particularly the HPA, when supported can stimulate the body’s own production and balance of hormones. In essence, improving this system allows the feedback and control of hormone production to be self-regulating without the burden to liver biotransformation that exogenous hormones appear to have. When a post-menopausal woman can improve her ability to produce her own hormones with changes in menopausal symptoms, bone mineral density scores, and cardiovascular support, then we have something to write about. This approach can be used in conjunction with hormone therapy in order to be in line with the recommendation of smallest dose, shortest duration of time. This is the question that should be asked. “What can we do, today, for women to be on the smallest dose of hormone replacement for the shortest amount of time and still retain quality of life?” The question should not be “is HRT good?”. More research into patient selection criteria is warranted. However, what I’m afraid will happen, at the expense of quality patient care, is disregard for these recommendation with some clinicians refusing to prescribe and others continuing to over-prescribe. We want something with a broad therapeutic window with no history of safety concerns. Something that supports endogenous hormone production so that lowest dose, shortest duration can be honored. We want something that has clinical trials that support efficacy in a broad spectrum of conditions the way HRT does. What we want exists and is available on the market as a natural product. Femmenessence (Maca-GO®) is that commercially available natural product. The following is a technical/ White Paper on the evidence of Femmenessence (Maca-GO®) http://naturalhi.com/downloads/WhitePaper_MacaGO.pdf and links to the abstracts of the peer-reviewed journal articles referenced http://naturalhi.com/Post-Menopause.aspx

St. John's Wort and Menopause

St. John’s wort products and extracts have been used for a wide range of medical conditions, the most common being depressive disorders. The most robust research is in the area of mild to moderate depression, with some additional research in anxiety, severe depression, seasonal affective disorder, premenstrual syndrome, and perimenopause/menopause. St. John’s wort is the most thoroughly researched natural antidepressant, but the majority of these studies have not been conducted on menopausal women.

A study of St John’s wort liquid extract showed a statistically decline in hot flashes severity, duration and frequency in the SJW group compared to placebo at week 8.[1]

Another double blind randomized clinical trial demonstrated that after 3 months of treatment, women in the St. John’s wort group reported significantly better quality of life scores, and significantly fewer sleep problems compared to placebo. [2]

About ten years ago, a non placebo controlled, drug monitoring study was conducted in women with menopause symptoms using 900 mg of St. Johns wort for 12 weeks. About three quarters of the women experienced improvement in both the self-rating scale and the physician rating, and significantly improved in psychological and psychosomatic symptoms as well as a feeling of sexual well-being.[3]

The first of three studies using St. John’s wort and black cohosh was published in 1999. This double-blind, randomized, placebo-controlled trial used St. John’s wort and black cohosh made by the makers of Remifemin.[4] The Kupperman index for the combination product decreased from 31.4 to 18.7 compared with a decrease in the placebo group from 30.3 to 22.3. Psychological symptoms also improved significantly in the black cohosh/St. John’s wort combination group.

A double-blind randomized placebo-controlled study was done using a combination trial of black cohosh and St. John’s wort. The mean Menopause Rating Scale score decreased 50% in the treatment group and 19.6% in the placebo group.[5] The Hamilton Depression Rating Scale score decreased 41.8% in the treatment group and 12.7% in the placebo group. In both testing measures the St. John’s wort + black cohosh group was significantly superior to the placebo group.

Another black cohosh/St. John’s wort trial was carried out in peri or postmenopausal Korean women, and was published in 2007.[6] Mean Kupperman index scores at 4 and 12 weeks were significantly lower in the treatment group (P < 0.002). At the end of the study, the average decrease in the Kupperman Index was 20 points in the treatment group and only 8.2 points in the placebo group (P < 0.001). Vaginal dryness and low libido were two symptoms that did not improve, but the average hot flash scores were significantly lower in the black cohosh/St. Johns wort group.

Finally, a study was done in which a combination of black cohosh with or without St. John’s wort was used in 6141 women at 1287 outpatient gynecologists in Germany in a prospective, controlled open-label observational study.[7] The greatest changes occurred with the combination therapy for nervousness/irritability and mood swings, but in the area of depression, there was a reduction in both treatment groups.

St. John’s wort is emerging as an important clinical tool in treating perimenopausal/menopausal women—for hot flashes and/or depression and/or mood swings, as a single agent, or in combination with other therapies.

For more blogs and information from Dr Hudson go to http://www.drtorihudson.com

References


--------------------------------------------------------------------------------

[1] Abdali K, Khajehei M, Tabatabaee R. Effect of St. John’s wort on severity, frequency, and duration of hot flashes in premenopausal, perimenopausal and postmenopausal women: a randomized, double-blind, placebo-controlled study. Menopause 2010;17(2): 326-331.

[2] Al-Akoum M, Maunsell E, Verreault R, Provencher L, Otis H, Dodin S. Effects of Hypericum perforatum (St. John’s wort) on hot flashes and quality of life in perimenopausal women: a randomized pilot trial. Menopause. 2009 Mar-Apr;16(2):307-14.

[3] Grube B, Walper A, Whatley D. St. John’s wort extract: Efficacy for menopasual symptoms of psychological origin. Adv Ther 1999;16:177.

[4] Boblitz N, Schrader E, Henneicke-Von Zepelin H, et al. Benefit of a fixed drug combination containing St. John’s wort and black cohosh for climacteric patients-results of a randomised clinical trial )poster presentation from 6th Annual Symposium on Complementary Health Care, Exeter, England, December 2-4 1999). Focus Alt Comp Ther 2000;5(1):85-86.

[5] Uebelhack R, Jens-Uwe Blohmer, et al. Black cohosh and St. john’s wort for climacteric complaints. Obstet Gynecol 2006;107:247-255.

[6] Chung D, Kim H, Park K, et al. Black cohosh and St. John’s wort (GYNO-Plus) for climacteric symptoms. Yonsei Med J 2007;48(2):289-294.

[7] Briese V, Stammwitz U, Friede M, et al. Black cohosh with or without St. John’s wort for symptom-specific climacteric treatment- Results of a large-scale, controlled, observational study. Maturitas 2007;57:405-414.

St. John's Wort and Menopause by Dr Tori Hudson

Several studies of St. John’s wort alone and St. John’s wort with black cohosh have been able to demonstrate that these products are good options for perimenopausal and menopausal women with hot flashes, mood issues, sleep problems and quality of life.

In the newest of the St. John’s wort studies in perimenopausal/menopausal women, a total of 100 Iranian women with an average age of 50 participated in a randomized, double-blind, placebo-controlled clinical trial comparing St. John’s wort with placebo in the treatment of hot flashes.[1] 50 women received 20 drops three times daily of St. John’s wort extract (Hypericin) that contained hypericin 0.2 mg/mL and 50 women received a placebo of distilled water. The study duration was two months. Clinical exams and interviews were performed at baseline, 4 weeks and 8 weeks. Treatment effectiveness was measured evaluating frequency, duration and severity of hot flashes as the main objective of the study.

In women taking St. John’s wort, the frequency began to decline during the 1st and 2nd months, but showed more improvement during the 2nd month. There was no statistical change in hot flash frequency during the first month of placebo but did improve during the second month. Women who used St. John’s wort showed more improvement in hot flash frequency than placebo. The decline in duration of hot flashes was statistically significant at week 8 and the decline was much more evident in the St. John’s wort group. The severity of hot flashes was relieved in the St. John’s wort group during the 2 months of treatment and was more significant in the second month. Women in the placebo group did not show any significant decrease in severity of hot flashes during the 1st month, but they did have some improvement during the 2nd month, but not as great as those women in the St. John’s wort group.

Comments
St. John’s wort has emerged as an important clinical tool in treating perimenopausal/menopausal women—for hot flashes and/or depression and/or mood swings, and/or sleep problems either as an encapsulated standardized extract from 300 mg twice per day to three times per day, or a tincture/liquid extract ½ tsp 2-3 times per day, or in combination with other menopause therapies such as black cohosh, maca extract, kava or others.

Reference
[1] Abdali K, Khajehei M, Tabatabaee R. Effect of St. John’s wort on severity, frequency, and duration of hot flashes in premenopausal, perimenopausal and postmenopausal women: a randomized, double-blind, placebo-controlled study. Menopause 2010;17(2): 326-331.

St. John's Wort for treatment of Premenstrual Syndrome (PMS) by Dr Tori Hudson

The results of a randomized, double-blind, placebo-controlled crossover trial using St. John’s Wort for PMS sufferers were recently published. 36 women with regular menstrual cycles who were diagnosed with mild PMS were randomly assigned to receive St. John’s Wort tablets (900 mg/day and standardized to 0.18% hypericin and 3.38% hyperforin) or placebo for two menstrual cycles. After a one month no treatment cycle, women were crossed over to the opposite group, for two additional cycles.

Symptoms were rated using the Daily Symptom Report, The State Anxiety Inventory, the Beck Depression Inventory and the Aggression Questionnaire and Barratt Impulsiveness Scale. Numerous hormones and physiological markers were also measured in the follicular and luteal phases: follicle-stimulating hormone (FSH), luteinizing hormone (LH), estradiol, progesterone, prolactin, testosterone, cytokine interleukins= IL-1B, IL-6, IL-8, interferon and tumor necrosis factor alpha.

St. John’s wort was statistically more beneficial than placebo in food cravings, swelling, poor coordination, insomnia, confusion, headaches, crying and fatigue. There were no significant effects of St. John’s wort compared with placebo in any of the biochemical blood measurements. St. John’s wort was not statistically more beneficial in anxiety, irritability, depression, nervous tension, mood swings, feeling out of control and pain-related symptoms during two cycles of treatment. However, these pain-related symptoms appeared to improve more than placebo towards the end of each treatment period.

Commentary: The results of this PMS study demonstrate once again, the benefit of St. John’s Wort for the treatment of PMS. In this study, it was determined their PMS was mild. The benefit received by women taking St. John’s Wort was achieved during the first menstrual cycle in which it was taken. While St. John’s Wort did not prove to be statistically better than placebo for mood and pain-related PMS symptoms, the pain symptoms did appear to improve more than placebo towards the end of each treatment period, implying that there may be more pain benefits with St. John’s wort after a longer duration of treatment. Several other studies have shown benefit with St. John’s wort.

Reference: Canning S, Waterman M, Orsi N, et al. The efficacy of Hypericum perforatum (ST John’s Wort) for the treatment of premenstrual syndrome. CNS Drugs 2010; 24(3):207-225.