Psychotic symptoms and consumption of energy drinks: Case report.

ABSTRACT

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The consumption of energy drinks and their rapid expansion has created concern from a scientific and community point of view. These are drinks that contain caffeine as their most common active ingredient. We present the case of a patient with no psychiatric history with clinical presentation of psychotic symptoms after increased consumption of energy drinks. A review of existing literature is carried out on other cases of the appearance of psychosis after the consumption of these beverages in people without and with a psychiatric history, as well as cases in which the presentation of other psychiatric symptoms predominates in order to discuss the clinical impact. The consumption of energy drinks could represent a global public health problem due to the possible serious and still little studied adverse effects on physical and mental health.

Key words: Energy drinks, caffeine, psychosis (Source: MeSH)

INTRODUCTION

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Energy drinks are new products in the broad soft drink market. They are included in a variety of non- alcoholic beverages marketed for their perceived stimulating, energizing, and performance- enhancing effects. Today, hundreds of different brands are marketed with a significant variation in their caffeine content (ranging from the highest
50mg to 505mg per can or bottle) and caffeine concentration (ranging  from  2.5mg  to  17.1  mg per fluid ounce). The acute and long-term effects resulting from excessive and chronic consumption of these energy drinks are unknown until now.

The rapid increase of this consumption has created concern both in the scientific community and in public opinion, since it is spreading more and more among young people, and is especially related to entertainment and sports practice. In the European Union,  the  highest  prevalence  of  consumption was observed in teenagers, where 68% of them had consumed these drinks at least once during
2012. However, the prevalence of consumption in adults was 30% and 18% in children(1,2,3). Its main component, caffeine, can influence the activity of neuronal control pathways in the Central Nervous System (CNS) as well as in the peripheral system. The neuropsychiatric effects of caffeine are mediated by antagonism of adenosine A1 and A2A receptors in the CNS. Since adenosine inhibits dopaminergic neurotransmission, the blockade of A2A receptors by caffeine can increase dopaminergic activity. Antagonism of A1 receptors regulates the release of neurotransmitters such as glutamate or acetylcholine. Caffeine differs from other substances of abuse, because it triggers dopamine release in the prefrontal cortex rather than the nucleus accumbens.(4)

The following is the case of a patient who presented psychotic symptoms due to an increased consumption of energy drinks, and was treated in an outpatient clinic of the Psychiatry Unit at Villa El Salvador Emergency Hospital.

Clinical Case
Mr. V is a 44-year-old male patient, native of Lima,
married, with high school education, Catholic, and works as a moto taxi driver (public transport). He has a history of cocaine and alcohol use in youth, and for 2 years he has been consuming energy drinks with a high caffeine content: 2 bottles a day (“Volt”, 600 ml/day = 192 mg/100 ml) because he felt tired in the morning and at night, mentioning that “he could not work”. Two months before being treated for the first time in a public institution, he reported having increased his consumption to 4 (sometimes more) bottles per day (“Volt”, 1200 ml/day = 384 mg), in the morning and at night, saying that “he needed to work due to economic problems”, and that every time he stopped working he felt desperate and restless. After this increased consumption, he presented sudden changes in his behavior that were confirmed by his wife. Jealous and mystical-religious delusions (he thinks that “the devil wants his evil”, and has sent him the drinks  in  order  to  hurt  him”,  “he  has  to  pray for everything to settle”), frequent episodes of anxiety, visual hallucinations (shadows that want to attack him and the presence of a black dog at night saying that he is the devil) ,insomnia, joint pain somatization, impulsiveness, irritability, aggression and hostility towards his wife.

Mr. V received  a diagnosis for Caffeine-Induced
Psychotic Disorder and was treated with risperidone
2 mg/day, sertraline 50 mg/day, and gabapentin 300 mg/day. He also received psychological treatment, where an extension of his clinical and substance use history was conducted. Having attended Neurology consultations  by  referral  at  the  same  institution and having had an electroencephalogram test with a normal result; past history or current problems involving organicity were ruled out. Serum and urine laboratory tests were performed within normal ranges. Current consumption of psychoactive substances was ruled out.

During his follow-up sessions, for around 8 months, he presented signs of problems in his relationship and received a report for psychological abuse. On the other hand, by medical indication, he progressively decreased  his consumption of energy drinks and showed evidence of a decrease in  insomnia,  irritability,  visual  hallucinations jealousy and mystical-religious delusions; However, due to an irregular intake of sertraline and gabapentin and to the influence of relatives who recommended that he suspend medication because “they were bad for the liver”, anxiety and joint pain lowered at a slower pace. Risperidone intake was regular .

DISCUSSION

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Energy drinks mainly contain caffeine, taurine, inositol, riboflavin, pyridoxine, nicotinamide, other B vitamins, and various herbal derivatives.(5) Currently, there are many brands that offer drinks with a caffeine content that varies between 50 mg and 505 mg(6). Its consumption has been mainly associated with caffeine intoxication manifested by nervousness, anxiety, agitation, sweating, gastrointestinal disorders and tachycardia(7). However, some publications have associated psychiatric symptoms that develop after energy drink  consumption  with  the  contained  amino acids, including taurine, inositol, etc.(8,9,10)

In  the  review  of  scientific literature,  there  are cases that have been reported to develop after consumption of energy drinks in patients with no known history. Sharma reported a case of acute mania with no history of psychiatric illness that developed after excessive consumption of energy drinks and was treated with olanzapine (10 mg/day) (7). Also Cruzado et al. in 2014 reported the case of a patient with no psychiatric history who consumed
4 doses or sachets of Omnilife products and 5 cups of coffee daily, developing manic symptoms. His treatment was risperidone 3 mg/day and the cessation of substance use(10). In 2012, Szpak and Allen reported a patient with no psychiatric history who consumed 7 packets of energy drinks during several weeks and developed  suicidal behavior which disappeared after ceasing consumption.(11)

More specific reports have suggested that caffeine could contribute to the development of psychosis. Hedges et al. reported the case of an otherwise healthy individual who developed psychosis after extended high caffeine intake. Before developing psychotic symptoms, he had increased his caffeine intake to 10-36 cups/day. He had had no modification of his psychotropic  medication,  and  by  simply  cutting by half his caffeine intake, his paranoid symptoms disappeared within 3 weeks.(12,16)

On the other hand, in 2011, Tibrewal and Dhillon reported the case of a 52-year-old man diagnosed with Schizophrenia who showed aggravated psychotic symptoms after a few weeks of increased coffee consumption (up to 20-25 cups of coffee / day). In this case, olanzapine treatment to control acute psychotic symptoms was ineffective, however, upon reduction of caffeine consumption without further adjustment of psychotropic medications, his psychotic symptoms disappeared within 10 days.(13,16)

Among  other  reports,  Cerimele  et  al.  reported a similar case in which a 43-year-old man with schizophrenia showed aggravated psychotic symptoms after daily consumption of up to 8-10 cans of energy drinks (3629-4536 mg caffeine/ day) during 8 weeks. In this case, once he stopped drinking energy drinks and with no need of psychotropic medications, his psychotic symptoms improved after 10 days.(14,16)

In 2011, Menkes   reported a case of transient psychosis after a single dose of energy drink consumption (600 mg/day of caffeine) that lasted only  several  hours(15,16).    Lucas  et  al.  conducted a double-blind, placebo-controlled study to investigate the effect of regularly consumed doses of caffeine (10 mg/kg) on changes in symptoms among patients with schizophrenia and found that these uncommon doses of caffeine could increase psychotic and manic symptoms.(17)

In relation to the case presented, Mr. V also consumed high doses of caffeine daily (384 mg/day) in energy drinks. Although we cannot determine if the increase in caffeine consumption directly caused the appearance of psychotic symptoms, the temporal relationship between the onset and disappearance of exacerbated symptoms after cessation of consumption, suggests that caffeine could generate these symptoms due to its known effects at the CNS level. Considering other reports on patients with or without psychiatric vulnerability, caffeine consumption can aggravate their symptoms or develop them for the first time. Finally, we can conclude that due to their high caffeine content, consumption of energy drinks, can induce the development of psychiatric symptoms, especially psychotic symptoms. However, more studies  are  needed  as  well  encouragement  for more cases to be reported.

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