Caffeine-Induced Psychosis: Case Report

 By Dawson W. Hedges, MD, Fu Lye Woon, MA, and Scott P. Hoopes, MD

Case Report


• Caffeine use can cause depression, anxiety, agitation, and aggression.

• Caffeine may cause psychosis that when chronic may mimic other psychiatric conditions.

• Caffeinism should be considered in the differential diagnosis of psychosis.

Dr. Hedges is an assistant professor in the Department of Psychology and the Neuroscience Center at Brigham Young University in Provo, Utah. Mr. Woon is a doctoral student in clinical psychology in the Department of Psychology and the Neuroscience Center at Brigham Young University. Dr. Hoopes is an adjunct faculty member in the Department of Psychiatry at the University of Utah School of Medicine and in private practice in Boise, Idaho.

Faculty Disclosures: The authors do not have an affiliation with or financial interest in an organization that might pose a conflict of interest.

Submitted for publication: November 1, 2008; Accepted for publication: February 23, 2009.

Please direct all correspondence to: Dawson W. Hedges, MD, 1001 SWKT, Brigham Young University, Department of Psychology and the Neuroscience Center, Provo, UT 84602; Tel: 801-422-6357, Fax: 801-422-0602; E-mail:


As a competitive adenosine antagonist, caffeine affects dopamine transmission and has been reported to worsen psychosis in people with schizophrenia and to cause psychosis in otherwise healthy people.

We report of case of apparent chronic caffeine-induced psychosis characterized by delusions and paranoia in a 47-year-old man with high caffeine intake. The psychosis resolved within 7 weeks after lowering caffeine intake without use of antipsychotic medication. Clinicians might consider the possibility of caffeinism when evaluating chronic psychosis.


A 47-year-old successful male farmer with no history of psychiatric hospitalization presented with a 7-year history of depression, diminished sleep to as little as 4 hours/night, poor energy, explosive anger, decreased concentration, decreased appetite, anhedonia, and feeling of worthlessness.

Seven years before his first presentation, the patient had developed the conviction that people were plotting against him to drive him off of his farm and take his land. At least twice, when he had found dead livestock on his farm, the patient thought that it was part of the plot against him and would entertain no other possibilities.

The patient interpreted tire tracks in the driveway as belonging to the car of individuals trying to take his land, even though other more plausible possibilities existed. According to the patient’s wife, the subject interpreted many everyday occurrences as evidence of the plot.

Convinced of a plot against him, he installed surveillance cameras in his house and on his farm but never caught anything that would support his conviction that as part of the plot people were coming onto his farm at night. He became so preoccupied with the alleged plot that he neglected the business of the farm and eventually declared bankruptcy as a result. His preoccupation with the plot also led him to neglect the upkeep of his home, and he had his children taken from him because of unsanitary living conditions.

In addition to psychosis, the patient reported life-long difficulty sustaining attention, excessive talking, disorganization, distraction, and forgetfulness. He denied other features of anxiety and psychosis.

The patient reported drinking less than one case of beer annually. However, ~7 years before presentation, he had sharply increased his consumption of coffee from 10– 12 cups/day to ~36 cups/day, a change in coffee consumption corroborated by his wife who made much of the coffee for him at home. There was no history of psychosis before the increase in coffee consumption, but after the increased consumption, the patient developed paranoia. At presentation, the patient reported drinking >1 gallon of coffee/day.

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Substance-Induced Psychosis.

Semin Clin Neuropsychiatry. 1998 Jan;3(1):70-79.


San Diego Joint Doctoral Program in Clinical Psychology, San Diego


Intoxication and withdrawal from a variety of central nervous system depressants and stimulants may induce hallucinations or delusions, which, when unaccompanied by insight, are the hallmarks of psychosis. A substance-induced psychosis may, in many instances, present as an organic psychosis or as an independent mental disorder (eg, schizophrenia), complicating diagnostic efforts.

Ramifications of a misdiagnosed psychotic illness are potentially long-lasting and harmful to a patient. It is, therefore, crucial that health care providers be aware of the complex relationship between substance abuse, psychotic symptoms, and independent psychotic disorders. This report addresses substance-induced psychosis, by describing those psychotic symptoms most commonly associated with the abuse of specific drugs and alcohol, detailing useful diagnostic techniques and outlining treatment recommendations.

[PubMed – as supplied by publisher]

Cannabis-associated psychosis with hypomanic features.

Lancet. 1982 Dec 18;2(8312):1364-6.


The mental state of 20 psychotic men with high urinary cannabinoid levels on admission to a psychiatric hospital was compared with that of 20 matched cannabis-free controls. All patients underwent toxicological analysis to exclude the presence of alcohol and other exogenous agents.

Cannabis levels were measured by a semiquantitative enzyme immunological technique and mental state was assessed by the use of the Present State Examination (PSE), once shortly after admission and again 7 days later. The cannabis group showed significantly more hypomania and agitation and significantly less affective flattening, auditory hallucinations, incoherence of speech, and hysteria than did the controls.

Clouding of consciousness was absent in most cannabis patients. After 1 week the cannabis group showed marked improvement (particularly in the psychotic syndromes), whereas the controls remained virtually unchanged. There was no significant difference in amount of medication received between the two groups.

Our data suggest that a high intake of cannabis may be related to a rapidly resolving psychosis manifesting with marked hypomanic features, though often presenting as a schizophrenia-like illness.

[PubMed – indexed for MEDLINE]

Is fluoride-induced hyperthyroidism a cause of psychosis among East African immigrants to Scandinavia?

Med Hypotheses. 2009 May;72(5):501-3. Epub 2009 Feb 7. Is fluoride-induced hyperthyroidism a cause of psychosis among East African immigrants to Scandinavia?

Zachariassen KE, Flaten TP. SourceLaboratory of Ecophysiology and Toxicology, Department of Biology, Norwegian University of Science and Technology, NO-7491 Trondheim, Norway.


East African immigrants to Scandinavia are admitted to mental hospitals far more frequently than native Scandinavians. Most of these patients are admitted for psychosis, commonly ascribed to problems adapting to the new culture. However, psychosis is also known to be associated with hyperthyroidism, and the high frequency of psychosis among East Africans in Scandinavia may at least in part be due to hyperthyroidism rather than cultural problems. Large areas in East Africa are notorious for high natural concentrations of fluoride in water and plants.

Fluoride inhibits the production of thyroid hormones. To maintain normal thyroxin levels the body increases the capacity for thyroxin production. Goitre is caused by such a compensatory mechanism, and endemic goitre is widespread in many high-fluoride areas, even where dietary access to iodine is adequate.

When people from such areas arrive in a low-fluoride area, their elevated capacity to produce thyroid hormones may lead to hyperthyroidism and subsequently to psychosis. PMID: 19201548 [PubMed – indexed for MEDLINE]

[Acute psychosis after administration of bupropion hydrochloride (Zyban)].

Psychiatr Prax. 2004 Nov;31 Suppl 1:S140-1.

[Article in German]

Neumann M, Livak V, Paul HW.

Bezirksklinikum Gabersee.


A 29-year old had been admitted to our institution with acute onset of schizophreniform psychosis after 5-day administration of sustained-release bupropion hydrochloride, which had been prescribed for nicotine withdrawal in a daily dosage of 300 mg. Examination results were found to be completely normal, apart from a positive drug screen for cannabis. We hypothesize that bupropion had induced psychotic symptoms in this patient.

PMID: 15570532 [PubMed – indexed for MEDLINE]

Manganese and acute paranoid psychosis: a case report.

J Med Case Reports. 2011 Apr 12;5(1):146. [Epub ahead of print]

Verhoeven WM, Egger JI, Kuijpers HJ.



INTRODUCTION: Manganese regulates many enzymes and is essential for normal development and body function. Chronic manganese intoxication has an insidious and progressive course and usually starts with complaints of headache, fatigue, sleep disturbances, irritability and emotional instability.

Later, several organ systems may be affected and, due to neurotoxicity, an atypical parkinsonian syndrome may emerge. With regard to neuropsychiatry, an array of symptoms may develop up to 30 years after intoxication, of which gait and speech abnormalities, cognitive and motor slowing, mood changes and hallucinations are the most common. Psychotic phenomena are rarely reported.

CASE PRESENTATION: We describe the case of a 49-year-old Caucasian man working as a welder who was referred to our facility for evaluation of acute paranoid psychotic behavior. Our patient’s medical history made no mention of any somatic complaints or psychiatric symptoms, and he had been involved in a professional career as a metalworker. On magnetic resonance imaging scanning of his brain, a bilateral hyperdensity of the globus pallidus, suggestive for manganese intoxication, was found. His manganese serum level was 52 to 97nmol/L (range: 7 to 20nmol/L).

A diagnosis of organic psychotic disorder due to manganese overexposure was made. His psychotic symptoms disappeared within two weeks of treatment with low-dose risperidone. At three months later, serum manganese was decreased to slightly elevated levels and the magnetic resonance imaging T1 signal intensity was reduced. No signs of Parkinsonism were found and a definite diagnosis of manganese-induced apathy syndrome was made.

CONCLUSION: Although neuropsychiatric and neurological symptoms caused by (chronic) manganese exposure have been reported frequently in the past, in the present day the disorder is rarely diagnosed.

In this report we stress that manganese intoxication can still occur, in our case in a confined-space welder, and may present clinically with a paranoid psychotic state that necessitates a rapid diagnostic procedure in order to avoid the permanent structural brain damage that may occur with chronic exposure.

PMID: 21486469 [PubMed – as supplied by publisher]

Youtube Credit:  Uploaded by on Sep 22, 2010

Charlie Rose: The brain series part 1 The great mysteries of the human brain. ” The Charlie Rose Brain Series explores one of sciences final frontiers, the study of the human brain.
Over the next year Charlie will interview the most knowledgeable scientists and researchers in hopes of illuminating a new topic of study. Each monthly episode will examine different subjects of the brain, including perception, social interaction, aging and creativity.
We will also look at scientific discovery and advances in technology, in the hope that someday terrible illnesses such as depression, schizophrenia, and Alzheimer’s will be history.
Our special colleague on this journey is Dr. Eric Kandel. He is a psychiatrist and neuroscientist and professor at Columbia University. He’s also affiliated with the Howard Hughes Medical Institute.
He received the Nobel Prize in physiology or medicine in 2000 for his research into the biological mechanisms of learning and memory. ”
These videos are also available from the charlie rose website directly:

Steroid-induced mania in an adolescent: risk factors and management.

Can J Clin Pharmacol. 2001 Summer;8(2):109-12.

Couturier J, Steele M, Hussey L, Pawliuk G.

University of Western Ontario, London, Ontario N5Y 4L3, Canada.


Few studies have clearly defined the risk factors and management of steroid-induced mania, particularly in children and adolescents. The case study of a 15-year-old woman with steroid-induced mania is examined to delineate risk factors and management. Genetic predisposition to mood disorders, previous exposure to steroids and the concomitant use of clarithromycin are potential risk factors. Mood stabilizers such as lithium and/or valproic acid may be useful in the acute and prophylactic treatment of steroid-induced mania.

PMID: 11493940 [PubMed – indexed for MEDLINE]

Psychotropic drug-related eosinophilia with systemic symptoms after acute caffeine ingestion.

Pediatrics. 2011 Jan;127(1):e235-8. Epub 2010 Dec 6.

Mahapatra S, Belgrad JL, Adeoye MA.

Department of Pediatrics, Lucile Packard Children’s Hospital, 725 Welch Rd, Palo Alto, CA 94304, USA.


Drug-related eosinophilia with systemic symptoms (DRESS) is a potentially life-threatening, multiorgan condition that can result from drug treatment. Antiepileptic medications have provided the best-studied link of any class of medications.

Here, we report the case of a 16-year-old boy with long-standing bipolar disorder who was chronically treated with aripiprazole and fluoxetine and developed DRESS syndrome after ingestion of high doses of caffeine.

His classic presentation with fever, morbilliform rash, lymphadenopathy, and visceral involvement, including leukocytosis, eosinophilia, and hepatitis, was consistent with this diagnosis.

Furthermore, the patient’s symptoms dramatically improved after corticosteroid therapy and discontinuation of all psychotropic medications. We propose that the development of DRESS syndrome is a net result of inconsistent medication adherence coupled with the ingestion of near-toxic doses of caffeine, which can lead to rhabdomyolysis and, through renal impairment, lead to the accumulation of toxic oxidative metabolites of either or both psychotropic medications.

We also present one of the few reported cases of caffeine-induced rhabdomyolysis and propose its role in the development of DRESS in this patient.

PMID: 21135003 [PubMed – indexed for MEDLINE]

Methylphenidate-induced mania-like symptoms.

Indian J Pharmacol. 2011 Feb;43(1):80-1. Methylphenidate-induced mania-like symptoms. Chakraborty K, Grover S. Department of Psychiatry, Institute of Neurosciences, Kolkata, 185/1, A.J.C. Bose Road, Kolkata – 700 017; India. Abstract

Therapeutic dose of methylphenidate is known to cause adverse effects (psychosis or mania), albeit in a small number of cases. Signs and symptoms of adverse effects usually disappear on stopping the medicine. Data regarding the safety of methylphenidate in comorbid attention deficit hyperactivity disorder (ADHD) and mental retardation are nonexistent. We describe a case of an 11-year-old girl with ADHD and mental retardation treated with methylphenidate, who developed mania like symptoms requiring inpatient treatment. The index case required psychopharmacological intervention with sodium valproate and olanzapine as the symptoms did not subside even after 3 days. This case highlights the fact that one has to exercise caution while prescribing methylphenidate in patients with comorbid ADHD and mental retardation

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