Disorders due to use of caffeine

Description

Disorders due to use of caffeine are characterised by the pattern and consequences of caffeine use. Caffeine is a mild psychostimulant and diuretic that is found in the beans of the coffee plant (Coffea species) and is a constituent of coffee, cola drinks, chocolate, a range of proprietary 'energy drinks' and weight-loss aids. It is the most commonly used psychoactive substance worldwide and several clinical conditions related to its use are described, although severe disorders are comparatively rare considering its ubiquity. Caffeine Intoxication related to consumption of relatively higher doses (i.e., > 1 g per day) is described. Caffeine Withdrawal is common upon cessation of use among individuals who have used caffeine for a prolonged period or in large amounts. Caffeine-Induced Anxiety Disorder has been described, often following intoxication or heavy use. [1]

Diagnostic requirements

WHO clinical descriptions and diagnostic requirements [1,2].

Subcategories

• 6C48.0 Episode of harmful use of caffeine

  An episode of caffeine use that has caused damage to a person’s physical or mental health. Harm to health of the individual occurs due to one or more of the following: (1) direct or secondary toxic effects on body organs and systems; or (2) a harmful route of administration. This diagnosis should not be made if the harm is attributed to a known pattern of caffeine use. [1]

  Essential (Required) Features:

  • An episode of use of caffeine that has caused clinically significant damage to a person’s physical health or mental health (e.g., Caffeine-Induced Mood Disorder), or has resulted in behaviour leading to harm to the health of others.
  • Harm to health of the individual occurs due to one or more of the following: (1) behaviour related to intoxication; (2) direct or secondary toxic effects on body organs and systems; or (3) a harmful route of administration.
  • Harm to health of others includes any form of physical harm, including trauma, or mental disorder that is directly attributable to behaviour due to Caffeine Intoxication on the part of the person to whom the diagnosis of Episode of Harmful Use of Caffeine applies.
  • Harm to health is not better accounted for by another medical condition or another mental disorder, including another Disorder Due to Substance Use (e.g., Substance Withdrawal).

  Note: Harm to the health of the person to whom the diagnosis applies includes injuries caused by behaviour related to intoxication (e.g., impulsive aggressive behaviour, psychomotor impairment leading to injury), acute health problems resulting from substance use (e.g., overdose, acute gastritis, the effects of hypoxia or prolonged hyperactivity or inactivity), and exacerbation or decompensation of pre-existing chronic health problems (e.g., hypertension, liver disease, or peptic ulceration). Harm may also result from a harmful route of administration (e.g., injecting drug use causing blood-borne virus infections, cocaine use causing a perforated nasal septum). The relevant diagnostic codes from other chapters of the ICD-11, including the chapter on Injury, Poisoning or Certain Other Consequences of External Causes, should be used to describe the specific health consequences of the harmful substance use.

  Harm to the health of others includes any form of physical harm, including trauma (e.g., impaired driving causing a motor vehicle accident, assaultive behaviour leading to bodily harm to another person) or mental disorder (e.g., Post-Traumatic Stress Disorder arising from an assault by the intoxicated individual) that is directly attributable to behaviour due to substance intoxication on the part of the person to whom the diagnosis of Episode of Harmful Psychoactive Substance Use applies.

  Additional Clinical Features:

  • There must be explicit evidence of harm to the individual’s physical or mental health, or of substance-related behaviour due to intoxication that has led to harm to the physical or mental health of others. There must also be a clear causal relationship between the harm to health and the episode of caffeine use in question.
  • The likelihood of harm to self or others due behaviour related to intoxication varies substantially by substance. For example, such behaviour is unlikely to arise from caffeine or nicotine intoxication.
  • Caffeine use commonly occurs in the context of other mental disorders. An additional diagnosis of Episode of Harmful Use of Caffeine can be made if the index episode of caffeine use has resulted in clinically significant harm to the individual’s physical health or has exacerbated or triggered an episode of a pre-existing mental disorder (e.g., a Manic or Depressive Episode or a psychotic episode).
  • A diagnosis of Episode of Harmful Use of Caffeine often signals an opportunity for intervention, typically a low intensity intervention that can be implemented in a wide range of settings that is specifically aimed at reducing the likelihood of additional harmful episodes or of progression to Harmful Pattern of Use.
  • As more information becomes available indicating that the episode is part of a continuous or recurrent pattern of caffeine use, or if additional harmful episodes occur, a diagnosis of Episode of Harmful Use of Caffeine should be changed to Harmful Pattern of Use of Caffeine, as appropriate.

  Boundary with Normality (Threshold):

  • The diagnosis of Episode of Harmful Use of Caffeine requires clinically significant harm to the individual’s physical or mental health or that of others. Examples of impact on physical or mental health that would not be considered clinically significant include mild hangover, brief episodes of vomiting, or transient depressed mood.
  • A range of social problems may be associated with an episode of substance use that are not sufficiently severe to constitute clinically significant harm to physical or mental health (e.g., missed appointments, arguments with loved ones). Such problems are not a sufficient basis for a diagnosis of Episode of Harmful Use of Caffeine.

  Boundaries with Other Disorders and Conditions (Differential Diagnosis):

  • Boundary with Hazardous Use of Caffeine: Hazardous Use of Caffeine is classified in the chapter on ‘Factors Influencing Health Status or Contact with Health Services’ in the ICD-11 and not in the chapter on Mental, Behavioural, and Neurodevelopmental Disorders. Hazardous Use of Caffeine appreciably increases the risk of harmful physical or mental health consequences to the user or to others to an extent that warrants attention and advice from health professionals, but has not resulted in specific identifiable harm and therefore does not meet the diagnostic requirements for Episode of Harmful Use of Caffeine.
  • Boundary with Harmful Pattern of Use of Caffeine: If the harm to health is a result of a known episodic or continuous pattern of substance use and all other diagnostic requirements are met, a diagnosis of Harmful Pattern of Use of Caffeine should be assigned. Substance use is generally considered to be following a pattern if there has been at least episodic or intermittent use over a period of at least 12 months. If harm is caused by use of caffeine but no information is available about the pattern or history of substance use, a diagnosis of Episode of Harmful Use of Caffeine may be assigned until such time as evidence for a pattern of use is ascertained.
  • Boundary with Caffeine Intoxication: Caffeine Intoxication is defined by caffeine use that results in clinically significant transient caffeine-specific symptoms. Recovery from Caffeine Intoxication is generally complete and without physical or mental sequelae. If there is continuing damage or harm (e.g., the effects of hypoxia, the effects of prolonged hyperactivity or inactivity, tissue damage) due to an episode of Caffeine Intoxication, a diagnosis of Episode of Harmful Use of Caffeine may be assigned. If relevant at the time of the clinical encounter (e.g., in emergency settings), Episode of Harmful Use of Caffeine may be diagnosed with an associated diagnosis of Caffeine Intoxication.
  • Boundary with Caffeine-Induced Mental Disorders: Caffeine-Induced Mental Disorders can be associated with a single episode of caffeine use. If a Caffeine-Induced Mental Disorder has occurred as a form of harm resulting from a single episode of caffeine use, both Episode of Harmful Use of Caffeine and the relevant Caffeine-Induced Mental Disorder should be diagnosed (e.g., Episode of Harmful Caffeine Use with Caffeine-Induced Anxiety Disorder).
  • Boundary with overdose: When ingestion of psychoactive substances results in symptoms of overdose (e.g., coma; life-threatening cardiac or respiratory suppression), a diagnosis from the grouping of Harmful Effects of Substances in the chapter on Injury, Poisoning or Certain Other Consequences of External Causes should also be assigned.
• 6C48.1 Harmful pattern of use of caffeine

  A pattern of caffeine use that has caused clinically significant harm to a person’s physical or mental health or in which caffeine-induced behaviour has caused clinically significant harm to the health of other people. The pattern of caffeine use is evident over a period of at least 12 months if use is episodic and at least one month if use is continuous (i.e., daily or almost daily). Harm may be caused by the intoxicating effects of caffeine, the direct or secondary toxic effects on body organs and systems, or a harmful route of administration. [1]

  Essential (Required) Features:

  • A pattern of continuous, recurrent, or sporadic use of caffeine that has caused clinically significant damage to a person’s physical health or mental health (e.g., Caffeine-Induced Mood Disorder), or has resulted in behaviour leading to harm to the health of others.
  • Harm to health of the individual occurs due to one or more of the following: (1) behaviour related to intoxication; (2) direct or secondary toxic effects on body organs and systems; or (3) a harmful route of administration.
  • Harm to health of others includes any form of physical harm, including trauma, or mental disorder that is directly attributable to behaviour related to substance intoxication on the part of the person to whom the diagnosis of Harmful Pattern of Use of Caffeine applies.
  • The pattern of caffeine use is evident over a period of at least 12 months if caffeine use is episodic or at least 1 month if use is continuous.
  • Harm to health is not better accounted for by another medical condition or another mental disorder, including another Disorder Due to Substance Use (e.g., Substance Withdrawal).

  Note: Harm to the health of the person to whom the diagnosis applies includes injuries caused by behaviour related to intoxication (e.g., impulsive aggressive behaviour, psychomotor impairment leading to injury; acute health problems resulting from substance use (e.g., overdose, acute gastritis, the effects of hypoxia or prolonged hyperactivity or inactivity), and exacerbation or decompensation of pre-existing chronic health problems (e.g., hypertension, liver disease, or peptic ulceration). Harm may also result from a harmful route of administration (e.g., injecting drug use causing blood-borne virus infections, cocaine use causing a perforated nasal septum). The relevant diagnostic codes from other chapters of the ICD-11, including the chapter on Injury, Poisoning or Certain Other Consequences of External Causes, should be used to describe the specific health consequences of the harmful substance use.

  Harm to the health of others includes any form of physical harm, including trauma (e.g., impaired driving causing a motor vehicle accident, assaultive behaviour leading to bodily harm to another person) or mental disorder (e.g., Post-Traumatic Stress Disorder arising from an assault by the intoxicated individual) that is directly attributable to behaviour due to substance intoxication on the part of the person to whom the diagnosis of Harmful Pattern of Psychoactive Substance Use applies.

  Course Specifiers:

  A specifier is used to further describe the harmful pattern of substance use, using a fifth-digit code. The fourth-digit code indicates the substance class (i.e., 8 for caffeine).

  6C48.10 Harmful Pattern of Use of Caffeine, episodic

  This category is assigned when all the diagnostic requirements for Harmful Pattern of Use of Caffeine are met and there is evidence of a pattern of recurrent episodic or intermittent use of caffeine over a period of at least 12 months that has caused clinically significant harm to a person’s physical or mental health or has resulted in behaviour leading to harm to the health of others.

  6C48.11 Harmful Pattern of Use of Caffeine, continuous

  This category is assigned when all the diagnostic requirements for Harmful Pattern of Use of Caffeine are met and there is evidence of a pattern of continuous caffeine use (daily or almost daily) over a period of at least 1 month that has caused clinically significant harm to a person’s physical or mental health or has resulted in behaviour leading to harm to the health of others.

  6C48.1Z Harmful Pattern of Use of Caffeine, unspecified

  Additional Clinical Features:

  • There must be explicit evidence of harm to the individual’s physical or mental health, or of related behaviour due to Caffeine Intoxication that has led to harm to the physical or mental health of others. There must also be a clear causal relationship between the harm to health and the episodic or continuous use of caffeine.
  • The likelihood of harm to self or others due behaviour related to intoxication varies substantially by substance. For example, such behaviour is unlikely to arise from caffeine or nicotine intoxication.
  • As more information becomes available about symptoms and behaviours related to the pattern of caffeine use as well as physiological features indicative of neuroadaptation to the substance, the diagnosis may be changed to Caffeine Dependence if diagnostic requirements are met.

  Boundary with Normality (Threshold):

  • The diagnosis of Harmful Pattern of Use of Caffeine requires clinically significant harm to the individual’s physical or mental health or that of others. Examples of impact on physical or mental health that would not be considered clinically significant include mild hangovers, brief episodes of vomiting, or transient depressed mood.
  • A pattern of caffeine use may cause a range of problems in functioning (e.g., missed appointments, arguments with loved ones) that are not sufficiently severe to constitute clinically significant harm to physical or mental health. Such problems are not a sufficient basis for a diagnosis of Harmful Pattern of Use of Caffeine.

  Developmental Presentations:

  • Harmful Pattern of Use of Caffeine is often a characteristic of late adolescence and young adulthood, and injuries and the consequences of aggressive behaviour are particularly common in this age group.
  • Harmful Pattern of Use of Caffeine in older adults may cause injuries and fractures due to the combination of lowered tolerance, psychomotor impairment induced by a substance, and disorders associated with ageing such as osteoporosis and Dementia.

  Sex- and/or Gender-Related Features:

  • The prevalence of Harmful Pattern of Use of Caffeine is higher in males than females, but the gender differential is smaller in countries where women play a greater role in the workforce. Gender differences in injuries and other forms of harm due to substance use are recognized.

  Boundaries with Other Disorders and Conditions (Differential Diagnosis):

  • Boundary with Hazardous Use of Caffeine: Hazardous Use of Caffeine is classified in the chapter on ‘Factors Influencing Health Status or Contact with Health Services’ in the ICD-11 and not in the chapter on Mental, Behavioural, and Neurodevelopmental Disorders. Hazardous Use of Caffeine appreciably increases the risk of harmful physical or mental health consequences to the user or to others to an extent that warrants attention and advice from health professionals, but has not resulted in specific identifiable harm and therefore does not meet the diagnostic requirements for Harmful Pattern of Use of Caffeine.
  • Boundary with Episode of Harmful Use of Caffeine: If the harm to health is a result of a single episode of use rather than a pattern of substance use, whether episodic or continuous, a diagnosis of Episode of Harmful Use of Caffeine should be assigned. Caffeine use is generally considered to be following a pattern if there has been at least episodic or intermittent use over a period of at least 12 months. If harm is caused by use of caffeine but no information is available about the pattern or history of caffeine use, a diagnosis of Episode of Harmful Use of Caffeine may be assigned until such time as evidence for a pattern of use is ascertained.
  • Boundary with Caffeine Dependence: In Caffeine Dependence, individuals use caffeine persistently despite harm and adverse consequences. Harm caused by such use may be similar to that observed in Harmful Pattern of Use of Caffeine. However, Caffeine Dependence also includes additional features of impaired ability to control use and increasing priority given to the substance use over other activities. Physiological features (e.g., tolerance) may also be present. If all diagnostic requirements for Caffeine Dependence are met, Harmful Pattern of Use of Caffeine should not be assigned.
  • Boundary with Caffeine Intoxication: Caffeine Intoxication is defined by caffeine use that results in clinically significantly, transient caffeine-specific symptoms. Recovery from Caffeine Intoxication is generally complete and absent of physical or mental sequelae. A pattern or repeated intoxication may or may not result in harm to a person’s physical or mental health or to the health of others. If there is continuing damage or harm as a result of repeated or continuous use of caffeine, a diagnosis of Harmful Pattern of Use of Caffeine may be assigned. If relevant at the time of the clinical encounter (e.g., in an emergency room), Harmful Pattern of Use of Caffeine may be diagnosed with an associated diagnosis of Caffeine Intoxication.
  • Boundary with Caffeine Withdrawal: Caffeine Withdrawal occurs upon cessation or reduction of a substance in the context of physiological dependence or when caffeine has been taken for a prolonged period or in large amounts. Some features of caffeine withdrawal may include physical or mental harm (e.g., headache, marked fatigue or drowsiness, nausea or vomiting, depressed or dysphoric mood). If the symptoms are entirely explained by the Caffeine Withdrawal, an additional diagnosis of Harmful Pattern of Use of Caffeine is not warranted. However, if the symptoms substantially exceed the expected withdrawal syndrome in duration or type or severity and the diagnostic requirements for Caffeine Dependence are not met, Harmful Pattern of Use of Caffeine can be assigned as the primary diagnosis, with an associated diagnosis of Caffeine Withdrawal.
  • Boundary with Caffeine-Induced Mental Disorders: If a Caffeine-Induced Mental Disorder has occurred as a form of harm resulting from a pattern of caffeine use, both Harmful Pattern of Use of Caffeine and the relevant Caffeine-Induced Mental Disorder should be diagnosed (e.g., Harmful Pattern of Caffeine Use with Caffeine-Induced Anxiety Disorder).
  • Boundary with other mental disorders and other medical conditions: Numerous mental disorders as well as subthreshold symptoms may co-occur with episodic or continuous patterns of caffeine use. Similarly, continuous or episodic caffeine use increases the risk for mental disorders as well as other medical conditions. Co-occurring mental disorders and comorbid medical conditions should be diagnosed separately, along with a diagnosis of Harmful Pattern of Use of Caffeine.
• 6C48.2 Caffeine intoxication

  Caffeine intoxication is a clinically significant transient condition that develops during or shortly after the consumption of caffeine that is characterised by disturbances in consciousness, cognition, perception, affect, behaviour, or coordination. These disturbances are caused by the known pharmacological effects of caffeine and their intensity is closely related to the amount of caffeine consumed. They are time-limited and abate as caffeine is cleared from the body. Presenting features may include restlessness, anxiety, excitement, insomnia, flushed face, tachycardia, diuresis, gastrointestinal disturbances, muscle twitching, psychomotor agitation, perspiration or chills, and nausea or vomiting. Cardiac arrhythmias may occur. Disturbances typical of intoxication tend to occur at relatively higher doses (e.g., > 1 g per day). Very high doses of caffeine (e.g., > 5 g) can result in respiratory distress or seizures and can be fatal. [1]

  Essential (Required) Features:

  • Transient and clinically significant disturbances in consciousness, cognition, perception, affect, behaviour, or coordination that develop during or shortly after the consumption or administration of caffeine.
  • The symptoms must be compatible with the known pharmacological effects of caffeine, and their intensity is closely related to the amount of caffeine consumed.
  • Presenting features of Caffeine Intoxication may include restlessness, anxiety, excitement, insomnia, flushed face, tachycardia, diuresis, gastrointestinal disturbances, muscle twitching, psychomotor agitation, perspiration or chills, and nausea or vomiting. Cardiac arrythmias may occur. Disturbances typical of Caffeine Intoxication tend to occur at relatively higher doses (e.g., > 1 g per day).
  • The symptoms of intoxication are time-limited and abate as caffeine is cleared from the body.
  • Symptoms are not better accounted for by another medical condition (See below) or another mental disorder, including another Disorder Due to Substance Use (e.g., Withdrawal from a different substance).

  Examples of Medical Conditions That May Present with Symptoms Similar to Substance Intoxication

  • Head injury (with or without cerebral contusion or intracranial haemorrhage or haematoma)
  • Meningitis and encephalitis
  • Diabetic ketoacidosis or hypoglycaemia
  • Hepatic or other metabolic encephalopathy
  • Wernicke’s encephalopathy
  • Electrolyte disturbance
  • Hypoxia or hypercapnia
  • Systemic infection

  Severity of Intoxication Specifier:

  Depending on the specific clinical situation and the information available, Substance Intoxication may be classified according to the level of severity as mild, moderate, or severe. The level of intoxication is usually related to the dose, route of administration, half-life, and duration of action of the substance. Severity of intoxication is also affected by individual variability (e.g., differences in body weight, substance metabolism, or tolerance). Susceptibility to substance intoxication may also be greater in individuals with comorbid medical conditions affecting drug pharmacokinetics (e.g., renal or hepatic insufficiency).

  For some substances, there are specific tests for detecting and determining the concentration of substances in bodily fluids (e.g., blood, urine), which can be important tools for clinical management. However, severity of intoxication should be determined on the basis of clinical assessment, as specified below, and not solely based on the presence and level of the substance in bodily fluids.

  The level of medical attention that may be required in response to substance intoxication varies according to the severity of intoxication and the substance involved, and varies from precautionary observation to urgent intervention to prevent death or permanent harm (e.g., administration of antagonist treatment; intubation).

  The severity of intoxication is classified using the following Extension (X) Codes in addition to the appropriate intoxication category. Extension codes are attached to the category to which they apply using an ampersand (&).

  XS5W Mild

  Mild substance intoxication is a state in which there are clinically recognizable disturbances in psychophysiological functions and responses (e.g., motor coordination, attention and judgement) that vary by substance, but there is little or no disturbance in the level of consciousness.

  The code for Caffeine Intoxication, mild is 6C48.3&XS5W.

  XS0T Moderate

  Moderate substance intoxication is a state in which there are marked disturbances in psychophysiological functions and responses (e.g., motor coordination, attention and judgement) that vary by substance, with substantial impairment on tasks that require these functions. There is some disturbance in level of consciousness.

  The code for Caffeine Intoxication, moderate is 6C48.3&XS0T.

  XS25 Severe

  Severe substance intoxication is a state in which there are obvious disturbances in psychophysiological functions and responses (e.g., motor coordination, attention and judgement) that vary by substance, with marked disturbance in level of consciousness. There is severe impairment to the extent that the person may not be capable of self-care or self-protection, and may be unable to communicate or cooperate with assessment and intervention.

  The code for Caffeine Intoxication, severe is 6C48.3&XS25.

  Additional Clinical Features:

  • Caffeine and related alkaloids (e.g., theobromine in tea) are present in a variety of foods (e.g., chocolate, kola nuts), beverages (e.g., sodas, guarana), and supplements (e.g., tablets, vitamins) that are consumed regularly and pervasively.
  • Very high doses of caffeine (e.g., > 5 g) can result in respiratory distress or seizures and can be fatal.
  • Psychoactive substances, whether of the same or a different pharmacological class, may interact such that they exacerbate or modify the features of intoxication. In cases of multiple psychoactive substance use in which more than one specific substance can be identified as a cause of the intoxication, it is recommended that the corresponding specific Substance Intoxication categories for each relevant substance be assigned (e.g., 6C40.3 Alcohol Intoxication and 6C48.3 Caffeine Intoxication) rather than 6C4F.3 Intoxication Due to Multiple Specified Psychoactive Substances.
  • Caffeine Intoxication may occur in the presence of medical conditions that cause impairment of levels of consciousness, cognition, perception, affect, behaviour, or coordination, which should be diagnosed separately. Determination of the aetiology of the disturbances in psychophysiological functions or responses may require longitudinal assessment.

  Boundary with Normality (Threshold):

  • Measurement of the presence or concentration of a substance in breath, blood, saliva, urine or other body fluids may be an important tool in the clinical management of Substance Intoxication. However, detection of a psychoactive substance in body fluids does not constitute a presumptive diagnosis of Substance Intoxication.

  Course Features:

  • The onset of Substance Intoxication varies according to the route of administration, the absorption of the substance and other pharmacokinetic factors. Generally, inhalation (smoking) and intravenous injecting routes lead to more rapid onset of intoxication, though oral ingestion may also lead to intoxication within minutes, depending on the substance.
  • Substance Intoxication is a transient condition, with the duration of intoxication depending on multiple factors including: (1) the dose of the substance taken, (2) the half-life and duration of action of the particular substance, and (3) the formulation of the substance taken (e.g., for pharmaceutical preparations, whether a controlled-release drug has been taken). Intoxication may last from a few minutes up to several days following the episode of use. The intensity of intoxication lessens with time after reaching a peak of absorption, and the effects eventually disappear in the absence of further use of the substance.

  Culture-Related Features:

  • The degree and characteristics of intoxication displayed for a given amount of a psychoactive substance varies considerably with circumstances, with beliefs and expectations about the effects of the substance, and with the cultural acceptability of displaying these effects. These factors result in cultural differences in the extent and manifestations of intoxication.
  • There are also genetic differences in susceptibility to intoxication with specific psychoactive substances associated with certain ethnic groups. Cultural and ethnically linked genetic factors have been better documented for alcohol than for other substances.

  Developmental Presentations:

  • Naïve users including adolescents can show features of intoxication at lower levels of use, reflecting lower physical and learned tolerance.
  • Older adults may have a lower tolerance than younger people to the effects of substances.

  Sex- and/or Gender-Related Features:

  • The amount of substance and duration of use necessary to cause intoxication differs by sex, reflecting differences in body weight and composition.
  • Behaviour while intoxicated may vary by gender, reflecting not only physiological differences, but also cultural differences and role expectations.

  Boundaries with Other Disorders and Conditions (Differential Diagnosis):

  • Boundary with Episode of Harmful Use of Caffeine and Harmful Pattern of Use of Caffeine: In Episode of Harmful Use of Caffeine and Harmful Pattern of Use of Caffeine, consumption or administration of caffeine results in damage to the person’s physical or mental health (including a Caffeine-Induced Mental Disorder) or in behaviour leading to harm to the health of others. Recovery from Caffeine Intoxication is generally complete. Complications due to such effects of intoxication such as injury, the effects of prolonged hyperactivity or inactivity, or other tissue damage should be diagnosed as Episode of Harmful Use of Caffeine or Harmful Pattern of Use of Caffeine, as appropriate. If relevant at the time of the clinical encounter (e.g., in emergency settings), Caffeine Intoxication can be given as an associated diagnosis, with Episode of Harmful Use of Caffeine or Harmful Pattern of Use of Caffeine as the primary diagnosis.
  • Boundary with Caffeine Withdrawal: Caffeine Withdrawal occurs upon cessation or reduction of caffeine in the context of physiological dependence or when caffeine has been taken for a prolonged period or in large amounts. In contrast, the onset of Caffeine Intoxication occurs immediately or shortly after the consumption of caffeine. Moreover the intoxication and withdrawal syndromes for caffeine are typically quite distinct.
  • Boundary with other Caffeine-Induced Mental Disorders: Mental or behavioural symptoms that arise during Caffeine Intoxication should only be used as a basis for diagnosing a Caffeine-Induced Mental Disorder if the intensity or duration of the symptoms is substantially in excess of those that are characteristic of Caffeine Intoxication and the symptoms are sufficiently severe to warrant specific clinical attention.
  • Boundary with other medical conditions: A variety of medical conditions may produce symptoms that are similar to those of Caffeine Intoxication. Some of these medical conditions are life-threatening requiring immediate intervention. Evidence of caffeine use (e.g., positive laboratory results) does not rule out the possibility of a comorbid medical condition. These alternative diagnoses must be considered in assessing Caffeine Intoxication. Certain medical conditions may also augment or prolong the duration of intoxication. Symptoms of intoxication that persist after they can no longer be reasonably attributed to the pharmacological effects of caffeine may suggest the presence of another medical condition. If it is determined that Caffeine Intoxication is comorbid with a medical condition, both diagnoses should be assigned.
  • Boundary with overdose: When consumption or administration of psychoactive substances results in symptoms of overdose (e.g., coma; life-threatening cardiac or respiratory suppression), it is typically more appropriate to apply a diagnosis from the grouping of Harmful Effects of Substances in the chapter on Injury, Poisoning or Certain Other Consequences of External Causes rather than Substance Intoxication.
• 6C48.3 Caffeine withdrawal

  Caffeine withdrawal is a clinically significant cluster of symptoms, behaviours and/or physiological features, varying in degree of severity and duration, that occurs upon cessation or reduction of use of caffeine (typically in the form of coffee, caffeinated drinks, or as an ingredient in certain over-the-counter medications) in individuals who have used caffeine for a prolonged period or in large amounts. Presenting features of Caffeine withdrawal may include headache, marked fatigue or drowsiness, irritability, depressed or dysphoric mood, nausea or vomiting, and difficulty concentrating. [1]

  Essential (Required) Features:

  • The presence of a clinically significant cluster of symptoms, behaviours, and/or physiological features that occurs upon cessation or reduction in the use of caffeine in individuals who have developed dependence on caffeine or have used caffeine for a prolonged period or in large amounts.
  • Presenting features of Caffeine Withdrawal may include headache, marked fatigue or drowsiness, irritability, depressed or dysphoric mood, nausea or vomiting, and difficulty concentrating.
  • The severity and duration of Caffeine Withdrawal is related to the amount, frequency and duration of caffeine use prior to cessation of use.
  • The symptoms are not better accounted for by another medical condition or another mental disorder.

  Additional Clinical Features:

  • Onset of Caffeine Withdrawal is typically 12 to 48 hours after the last use and may last up to 7 days.
  • Characteristic features of Caffeine Withdrawal are opposite to the acute pharmacological effects of caffeine.
  • Caffeine Withdrawal symptoms become more severe with repeated episodes of withdrawal (termed ‘kindling’), with aging, or in the presence of comorbid medical conditions.

  Boundary with Normality (Threshold):

  • Caffeine Withdrawal should only be diagnosed when symptoms are consistent with those recognized as occurring upon cessation or reduction in use of caffeine. Recent cessation or reduction of use and the presence of various non-specific transient symptoms is not sufficient to make the diagnosis of Caffeine Withdrawal.
  • Withdrawal symptoms should be differentiated from the transient physiological aftereffects of intoxication (‘hangover effect’).
  • Some individuals who have previously had Caffeine Dependence may experience symptoms similar to those of Caffeine Withdrawal months after the last use of the substance, particularly when the individual encounters stimuli (e.g., drug paraphernalia) and contexts (e.g., location where use was frequent) previously associated with past caffeine use. These symptoms are more transient than those observed during Caffeine Withdrawal and occur exclusively when in contact with associated stimuli and contexts. A diagnosis of Caffeine Withdrawal should not be assigned under these circumstances.

  Course Features:

  • Caffeine Withdrawal is time-limited. Factors that influence the features and time course of Caffeine Withdrawal include: (1) the severity of Caffeine Dependence, if present, (2) the dose, frequency of use, and duration of caffeine use prior to cessation or reduction of that use, (3) the half-life and duration of action of caffeine, and (4) the presence of comorbid medical conditions (e.g., metabolic disturbances).

  Culture-Related Features:

  • Symptoms of withdrawal depend largely on the psychotropic characteristics of caffeine. However, specific cultures may emphasize certain symptoms of withdrawal over others, making it more difficult to conduct a differential diagnosis. In addition, vernacular terms for withdrawal vary greatly.

  Boundaries with Other Disorders and Conditions (Differential Diagnosis):

  • Boundary with Caffeine Intoxication: The onset of Caffeine Intoxication occurs immediately or shortly after the consumption of caffeine. In contrast, Caffeine Withdrawal occurs upon cessation or reduction in the amount of caffeine in the context of Caffeine Dependence or when caffeine has been taken for a prolonged period or in large amounts. For caffeine, the intoxication and withdrawal syndromes are typically distinct.
  • Boundary with other Caffeine-Induced Mental Disorders: Mental or behavioural symptoms that arise during Caffeine Withdrawal should only be used as a basis for diagnosing a Caffeine-Induced Mental Disorder if the intensity or duration of the symptoms is substantially in excess of those that are characteristic of the Caffeine Withdrawal and the symptoms are sufficiently severe to warrant specific clinical attention. In such cases, if the withdrawal syndrome is ongoing, diagnoses of both Caffeine Withdrawal and a Caffeine-Induced Mental Disorder may be assigned.
  • Boundary with other mental disorders: Various symptoms associated with Caffeine Withdrawal overlap with those that are characteristic of other mental disorders (e.g., depressive and anxiety symptoms). Symptoms of Caffeine Withdrawal occur in specific temporal relationship to the cessation of use of caffeine and diminish with the passage of time. Evidence supporting a mental disorder diagnosis would include the symptoms preceding the onset of caffeine use, the symptoms persisting for a substantial period of time after cessation of caffeine or withdrawal (e.g., 1 month or more, depending on the substance), or other evidence of a pre-existing mental disorder (e.g., a history of prior episodes not associated with caffeine use).
  • Boundary with other medical conditions: It may be difficult to distinguish between various symptoms associated with Caffeine Withdrawal (e.g., headache, nausea or vomiting, fatigue) and those that are characteristic of other medical conditions. Symptoms of Caffeine Withdrawal occur in specific temporal relationship to the cessation of use of caffeine and diminish with the passage of time.
• 6C48.4 Certain specified caffeine-induced mental or behavioural disorders

Coded elsewhere

• Hazardous use of caffeine (QE11.5)
• Disorders due to use of stimulants including amphetamines, methamphetamine or methcathinone (6C46)

References

1. World Health Organization. International Classification of Diseases, 11th Revision, for Mortality and Morbidity Statistics (ICD-11 MMS), 2026-01 release. World Health Organization; 2026.
2. World Health Organization. Clinical Descriptions and Diagnostic Requirements for ICD-11 Mental, Behavioural or Neurodevelopmental Disorders (CDDR). World Health Organization; 2024.

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