May 23rd, 2012

Diagnosis Discourse: Caffeine Withdrawal in DSM-V

I'm just going to preface this by saying: I'm completely serious in thinking this diagnosis belongs in DSM-V. If you're looking to see if this was posted on April 1 or other indications that I'm kidding, I'm thinking bad thoughts about you as a person because you aren't paying attention.

The current manual for coding diagnoses in the mental health field is the DSM-IV-TR (4th edition of the DSM, text revision which means some words were changed but structure wasn't and new sections weren't added or sections deleted, more or less). The fifth edition (DSM-V) has been in process for a while. As of the end of April, this is the entry for "Caffeine Withdrawal":

"A. Prolonged daily use of caffeine.
B. Abrupt cessation of caffeine use, or reduction in the amount of caffeine used, 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/stiffness
C. The symptoms in Criterion B cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
D. The symptoms are not associated with the direct physiological effects of another medical condition (e.g., migraine, viral illness) and are not better accounted for by another mental disorder."

You can go there and read the Rationale Tab; I'm not reproducing it here but I will provide an unprofessional and likely inaccurate in some important way that is not obvious to me summary. People who drink coffee or otherwise consume caffeine regularly who stop get the worst headache of their life and it lasts for days and it makes them less able to perform at work or school and cranky to the people around them. People who consume caffeine have to arrange their lives for regular supply or risk having this occur and it can be highly disruptive if their usual routine for getting it is interrupted. When these people stop drinking coffee without realizing this can occur (or for reasons not under their control such as hospitalization or institutionalization), the resulting symptoms can trigger a testing cascade that is expensive, pointless and potentially dangerous.

I will include one paragraph from the Rationale:

Benefits of Inclusion of Caffeine Withdrawal

"As reviewed above, many caffeine users may have caffeine withdrawal and misattribute it to other causes or ailments. If patients and their health care providers were more aware of caffeine withdrawal symptomatology, unnecessary health care utilization and costs could potentially be avoided. For example, caffeine withdrawal should be ruled out when patients present with headache and other typical caffeine withdrawal symptoms before administering expensive diagnostic tests or medications. For example, a simple 2 day caffeine abstinence test could assess for caffeine withdrawal headache and might eliminate the need for more expensive diagnostic procedures. In addition our anecdotal experience is that often psychiatrists ignore the possibility of caffeine withdrawal as a cause of headaches, fatigue, depression, etc. This may occur often when patients are admitted to caffeine-free inpatient units. The inclusion of caffeine withdrawal as a diagnosis in the DSM-5 will engender an awareness of this potentially clinically significant syndrome."

So the next time you're thinking that no way could so-and-so have such-and-such a problem because of a criterion like "C. The symptoms in Criterion B cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.", bring caffeine withdrawal to mind. We all know about it. We tend to be dismissive about it. We tend to forget that the consequences of it going _undiagnosed_ can be substantial. By "diagnosed", I don't mean, "going to a neurologist every time you decide to cold turkey off coffee so it starts working for you again when you go back on". I mean "know that this can happen". The writers of DSM-V have an expectation that patients can and will self-diagnose for this and intend by including this in the manual to help them do that self-diagnosis better.

Interested in an example of how inclusion in the diagnostic manual works its way out to ordinary people like you or me?

Sample news coverage:

Recent Activities include: T. the Personal Organizer

T. has long had a, um, some set of words, for order and routine. Love? Attachment? Need? Whatever.

What this is like in every day life is that he has a set of things he'd like to do during the day and some ordering to those activities. In the morning, this is fantastic: he's pretty easy to get dressed, get some food in front of him, get him out the door. His agenda mostly revolves around getting his sister's bag packed up and in the white van. That's more of a problem, especially if her lunch isn't ready before he needs to get in the van (different van) to go to school.

In the afternoon, it's pretty good, too: he'll want to go ride on scooters, and maybe have a popsicle or go get some food at the grocery store or Wendy's. He likes watching R. do a Snap Circuits project, finger paint, etc.

I recently moved A.'s size 4 clothing along to younger children and T.'s size 6 clothing along as well. In the process, T. decided that taking a paper bag upstairs and filling it with clothes and then putting it in the white van to go to work with R. is An Activity. This doesn't make R. happy, however, T. has been remarkably cooperative about not stuffing things into the bag independently; he'll let an adult run the process as long as he gets to help and bring the bag downstairs.

So I have a Personal Organizer who, once a day (sometimes twice), urges me to go look around for things that we really should have gotten rid of already because we don't use them and they still have useful life in then, put them in a bag, and get them out of the house. Who knew kindergartners could be so helpful?