Yes, Virginia — Coffee Can Cause Illness

Ahh – 19 years old!  It is a magical age.  At least it has been my experience in public mental health clinics.

You see, almost without exception any male of 19 years who appears in my office – is a really messed up and sometimes just, plain rotten fellow.

I don’t know what it is about 19.

One of the typical cases – though legally an adult — was functionally a kid, living with his parents and acting out the same kind of adolescent rebellion that most go through at 14 or 15 and out-grow by 17.

Oh, he had it all — One of those cylinders in his earlobe, spreading a hole from a small piercing to the size of a basketball. He told me it was “tribal.” He was a music major at a local, broken down branch of the state college.  He wanted to be a performance artist.

Sure.  I am at the point where I expect pretty much any genuinely-gifted musician to be bipolar — and he was not.

He asked me for Xanax and lots of it.  That, coupled with just being a typical 19-year-old punk was enough to boil my blood. But I’m a professional – I maintained my cool.

I flipped a page in his chart and saw he had been on exactly the dose of Xanax he was requesting — a high one — since he started being seen at the clinic at age 18.  And before that, he had gotten the same dose from a child psychiatrist.

I despair of my colleagues who seem to have a drug habit – a drug PRESCRIBING habit — and give patients more than they need as often as they want.  I don’t know who they think they are helping.

Now, at least, I had some other people I could get angry at, so I could be a little more relaxed as I got the history of this fine young fellow.

The chart listed “panic disorder” as his diagnosis and he described to me the classical symptoms.  Duration usually not over 15 minutes or so.

Shaky, sweaty, had to stop what he was doing and run from the place … yeah, I could see that someone who hadn’t been kicking around in the field as long as me – or had been exposed to too many 19-year-old punks and was burned out — would think this was a panic disorder.  But I learned long ago that the only serious errors I make come when I trust other doctors.  This did not seem right and I could not put my finger on why, so I started from zero.

Family history — negative for any kind of anxiety disorder.  No, this thing was not genetic.  First degree relatives are 4 to 7 times more likely to develop this disorder.

I took a pretty standard history.  It had started at 15 or 16 or so, and he had some bona fide family type stressors.  Dad had allegedly murdered Mom by throwing her out of a window to her death, and was now, appropriately jailed.

My patient was a student who finally admitted to me that he was working his way through school, living with “friends;” the more he tried to explain, the messier he got.  I could assign him a social worker.  But I tried to do as complete a history as I could, and it was tough.

I always routinely ask about coffee intake.

“About a pot a day.”

How many cups in a pot? “About 30.” He needed it to stay awake for work (he was doing fast food work) and school.

The lightbulb went on.  No wonder a kid his size – small — could easily sleep with all that Xanax.

I pulled out the nearest copy of DSM-IV — the  Diagnostic and Statistical Manual of Psychiatry, fourth edition.  This is the Bible that everyone who dishes out this kind of psychotropic prescription needs to live by, although it is rarely diagnostic and gives little in the way of statistics.

It does say that anybody who presents with Panic Disorder ought to have thyroid problems and caffeinism ruled out — which of course he never had.

I showed it to him.  Maybe he would believe something from a book.
Adolescent boys are never terribly excited about believing things that mature women say.  I’d learned this the hard way.

As for the pharmacology of caffeine, I learned the basics within the first few hours of pharmacology lecture in medical school in Amiens, France.  My classmates and I all listened in horror to the description of the self-same chemical that kept us awake throughout those nights on call.

Our prof had a wicked sense of humor, and started by telling us about the myths of the near East (from which many of my classmates came) about how goats who chomped coffee berries off the trees got a little more “frisky.”

He told us to forget all that stuff immediately, for this was a multivalent-type drug – meaning  “having many effects” — that was such a real drug that if someone tried to introduce this today as a new drug for the prescription pharmaceutical market, it would have trouble getting pasy the United States FDA (or even the French equivalent).

Caffeine is a Xanthine.

We are talking about a group that includes mild stimulants and bronchodilators.  Drugs like theophylline (I think we got much, much, better ones now) were the gold standard for years for control of asthma.  They can theoretically be lethal, but thank heaven nobody can tolerate them and we get other problems first.  This group of chemicals is related to the purines, one of the most basic bases of DNA.

The mild stimulation effect has helped many — including medical students (like me) — get through numerous long nights on call, and sometimes, the following days working the wards and operating rooms.

Nobody known to me consumed enough to make it through to the proconvulsant effect.  Yes — coffee can cause a seizure that standard anticonvulsants would not be able to stop.

Everyone seemed to know that you just don’t give chocolate to a dog.  It contains the chemically-related theobromine , which is a fine way to give bowser a seizure.

One classmate claimed he actually had (whether through ignorance or as some kind of mad scientist experiment – or just cruelty). This guy — who allegedly is now practicing in the greater Parisian region — said that his spaniel was never quite the same.  Thank goodness, he was only licensed to treat humans and not as a veterinarian!

Xanthines are also diuretics.  Frequenting the rest room for expulsion of superfluous fluid is indeed part of the memory of any medical student who has been on-call.

Xanthines are also pretty good bronchodilators.  I remember my hay fever seemed to magically improve when I was on call, even in the spring when the plants at the University Hospital Center of the Picardy region were in full pollination. I seemed to be sneezing continuously when I was not on call.

Coincidence? I think not.

As for my patient in  that rural California who considered himself an incipient performance artist thanks to the broken down California University system, the best thing about him was that he did not much like the Xanax and was actually pretty happy about the idea of getting off of it.

I did go ballistic when he suggested cold turkey.  It would have to be gradual.  With that amount of caffeine, he would get an intractable headache that could only be relieved by taking caffeine.

Many patients are surprised to learn that caffeine is a wonderful cerebral vasoconstrictor (it makes the blood vessels narrower), and is part of many headache medications – migraine and otherwise.

Some folks use its bronchodilation effects in an emergency, giving some coffee to children, who are having an acute asthmatic attack.  Of course, now that children seem to spend a lot of their spare time and allowance at Starbucks, it might have to be a much bigger coffee than when I was in medical training.  Probably a Vente at least – whipped cream optional.

We worked out a schedule of tapering off both the coffee and Xanax.  Let’s just say that he was not a guy for schedules – an under-statement.

We worked out frequent visits and got him working with the nurse.

He had gotten off 50% of his Xanax and 50% of his coffee by the time I left that clinic for a place where the weather better suited my clothes.

Biggest surprise to all concerned was that his mediocre grades were improving, as were his academic aspirations.  He still loved his performance art, but was beginning to wonder if he couldn’t pay his way in life by being a music teacher; a question that remained beyond my competencies.

Maybe coffee causes “Responsibility Deficit Disorder.”  Hmm – maybe I can get a grant to study that. But I won’t count on Starbucks funding me.