Tale Of A Caffeine Fiend

I had a patient once, long ago and far away, who was the worst “Caffeine Fiend” – properly known as “caffeinism” in medical lingo — I had ever heard of. 

He was only 27 but depression and obesity added ten or fifteen years to his appearance. He was single and did not have much of a social life, but he did not much care.  He was one of the earlier generation of people to build himself a career doing something with computers, with some sort of techie abilities which I could not understand at all. That enabled him to work from home at least part of the time, and only occasionally would he have to make a mad run to and from his employers’ office. This was in rural northern California, somewhat removed from the Silicon Valley mainstream of this type of activity.

The “from” part was important, as he did not much like to hang around with other humans, much preferring the company of his computer.

I understand that the computer geeks of today chug Red Bull or some equivalent constantly.  Back in the day, he was drinking about eight pots of coffee daily – gigantic pots with about twenty cups of coffee in each pot.

A Dickens Of A Problem

I do not remember his exact weight — he was a bit shy about revealing it and the one time he came into my the office, we did not have a scale that was safe — let alone readable — over 300lbs.  He was estimated at about 320 lbs.  This is about what I weighed at my heaviest, but I remember he was nearly a foot shorter than me, and I’m considered tall at about 5 foot 8 inches.

As far as I could figure, the problem was something we call Pickwickian syndrome after the obese red-faced boy who had the characteristic trouble breathing in Charles Dickens’ novel “The Pickwick Papers”.  In a delightful example of art mirroring life, Charles Dickens described what we now know as basically a form of sleep apnea — and it can be treated as such.  Characteristically, this is found in people with a short thick neck, who have flaccid breathing apparatus that tends to collapse the airway.

People who do not get enough oxygen wake up.  They are not only sleepy during the day, but often nervous and depressed.  I am usually quite gratified, as is the patient, when we can diagnose this. Usually a sleep study will confirm, although I have no problem recommending someone for treatment just on their story.

Treatment classically consists of a continuous positive airway pressure (CPAP) machine where the pressure on the air being breathed in keeps that windpipe open and functional. 

People tend to hate this and often rip the thing off during their sleep.  Why? Well, one patient once dared me to have sex wearing one of these cumbersome apparatuses.  He said even the simplest smooch became impossible.

An alternative – which may or may not be quite as effective – is a type of mouth piece (sometimes sold as a cure for snoring)

Weighting For A Cure

But what makes a Pickwickian extremely unhappy is informing him that the cornerstone of treatment is weight loss. This is usually a guarantee of non-compliance.

Losing weight usually means restricting food (when prescribed by most doctors.  I’m on record of calling this balderdash and sharing much less onerous and more useful methods).  So patients aren’t very keen on starving and giving up sensual eating pleasure just because they want to  sleep and breathe.

That rural California patient did not much want to have treatment for his caffeinism.  He loved food, considered himself a bit of a scientist, and felt his life was “equilibrated.”  

TOO MUCH IS TOO MUCH

There are lots of reviews and studies and analyses that suggest that too much caffeine is bad for you.  The roller coaster nervousness is probably the worst problem on the clinical side.  The paradox often arises of excess of fatigue with too much coffee.  Its role as a neural stimulant can simply leave you  OUTRAGEOUSLY stimulated. But then, that is the very reason some people drink so much of it.

Most specific example, in the Diagnostic and Statistical Manual of Mental Disorders (DSM IV) when you look under panic disorder, you really have to eliminate caffeinism before making ANY diagnosis, because it can cause panic attacks and something that is — well, a panic disorder. Still, with all its multivalent effects (a bit of a diuretic, raising blood pressure a bit) it is amazingly benign.  The patient in rural northern California did not want treatment, at least not very much.  We both knew that cutting back too much too quickly causes a horrible headache, which he did not want or need.  The only option would be a slow taper.

Since I was only there as a consultant and for a short time, the patient complained that he did not trust any other doctor to continue.  It could be cross-tapered with a “mild” stimulant, but those had side effects neither of us was too happy about.  Maybe, that distant cousin to stimulants, bupropion  — but not, he said, with another doctor. I could never ever have consumed anywhere near the amount of coffee this young man consumed.  My husband will testify that I do not seek more than one cup of coffee once in a rare morning.  For me, maybe two cups after a night of poor sleep is a real binge – but purely medicinal.  Too much more would put me in the realm of — well, panic disorder.

THE GENETIC CONNECTION

Recent work in this field tells me this is genetic.  This is believable, since my parents, whom I generally do not seek to emulate, were both people who would never dream of having more than one cup of coffee daily in the morning, also to avoid excessive jitters. One of the genes cited in the article is a member of the cytochrome p450 system (a family of over 60 enzymes the body uses to break down toxins, and make blood).  Variants on this gene metabolize different drugs. 

The study of this system has been used to sell antidepressants, of course.  But the knowledge of this system has also produced tests that may be given a person to determine what sort of drug, for example, what sort of antidepressant, they are most likely to respond to.  Of course, no insurance company in the world will actually pay for these tests.  So the poor little clinical psychiatrist is left with a guesswork we ennoble by calling it “art” — trying  to figure out, from real or imagined receptor profiles or clinical profiles, what will work.  It’s kind of like hunting and pecking on a keyboard when you do not really know how to type. So some people drink coffee all day to get the same effect others of us get from a single cup.  It remains to generalize from the profile, finding out what out else this gene complement  can make someone describe faster or slower.  Maybe something like– a cancer chemotherapy?  If someone could be cured with less, would they have the same side effects, or less?  Are side effects mediated by the same metabolism that determines efficacy? Inquiring minds want to know. In general, more things are determined genetically than anyone wants to believe. I still remember the shock of reading studies of identical twins separated at birth, a literature I have not looked at for years. I remember two identical twins separated at birth that had chosen the same obscure brand of toothpaste.  Wow. Perhaps the most powerful aspect of genetic knowledge is that we might be able to get away from the “one size fits all” kind of medicine, where screaming hordes undergo a clinical trial of a single medication treatment. To me, this is what “celebrate diversity” really means.