Development of the Caffeine Withdrawal Symptom Questionnaire: Caffeine withdrawal symptoms cluster into 7 factors

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Abstract

Background

Habitual caffeine consumers who abstain from caffeine experience withdrawal symptoms such as headache, fatigue, difficulty concentrating, mood disturbances, and flu-like symptoms (Juliano and Griffiths, 2004). The caffeine withdrawal syndrome has been documented across many experimental studies; however, little is known about how withdrawal symptoms co-vary during a discrete episode. Furthermore, a validated measure of caffeine withdrawal is lacking.

Objective

To develop, evaluate, and reduce a 23-item measure of caffeine withdrawal symptoms; the Caffeine Withdrawal Symptom Questionnaire (CWSQ), to a set of composite variables.

Methods

Caffeine consumers (N = 213) completed the CWSQ after 16 h of caffeine abstinence. A subset of participants also completed the CWSQ during a preceding baseline period and/or after double-blind consumption of caffeinated coffee.

Results

Principal components analysis resulted in a solution comprised of 7-factors: 1. Fatigue/drowsiness; 2. Low alertness/difficulty concentrating; 3. Mood disturbances; 4. Low sociability/motivation to work; 5. Nausea/upset stomach; 6. Flu-like feelings; and 7. Headache. With the exception of nausea/upset stomach, the CWSQ total score and individual composite scores were significantly greater during caffeine abstinence relative to both baseline and double-blind consumption of caffeinated coffee, thereby demonstrating sensitivity of the measure. Compared to non-daily coffee consumers, daily consumers had greater increases in total withdrawal, fatigue/drowsiness, low alertness/difficulty concentrating, mood disturbances, and headache.

Conclusions

Future directions include replication, assessment on a clinical population, and further examination of psychometric properties of the CWSQ. The CWSQ should facilitate the assessment and diagnosis of caffeine withdrawal and increase our knowledge of the caffeine withdrawal syndrome.

Introduction

Caffeine is the most widely used mood altering drug in the world. In the United States, 87% of children and adults regularly consume caffeine (Frary et al., 2005), with adult caffeine consumers ingesting approximately 280 mg per day on average (Barone and Roberts, 1996). The habitual use of caffeine produces physical dependence, which manifests as caffeine withdrawal symptoms upon acute abstinence. Caffeine withdrawal has been documented in animals and humans (Dingle et al., 2008, Juliano and Griffiths, 2004, Sigmon et al., 2009), with the biological basis believed to be increased functional sensitivity to endogenous adenosine via the upregulation of adenosine receptors (Ferre, 2008). Caffeine withdrawal symptoms typically emerge after 12–24 h of caffeine abstinence, peak in the first day or two, and last from 2 to 9 days (Juliano and Griffiths, 2004). Caffeine withdrawal can impair normal functioning (e.g., incapacitating headache, missing work; Juliano and Griffiths, 2004, Strain et al., 1994), and it has been suggested that fatigue and performance decrements resulting from acute caffeine abstinence may have important implications for safety (e.g., sleepiness while driving) and academic achievement (Heatherley et al., 2006, James and Keane, 2007, James et al., 2011).

In 1994 caffeine withdrawal was added to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) as a proposed diagnosis (Hughes, 1994). Tentative criteria were put forth consisting of headache plus one or more of the following symptoms: 1. Marked fatigue or drowsiness, 2. Marked anxiety or depression, and 3. Nausea or vomiting (American Psychiatric Association, 1994). In 2004 Juliano and Griffiths conducted a comprehensive review of caffeine withdrawal research and found highly convincing empirical support for the following symptoms: headache, fatigue, decreased energy/activeness, decreased alertness, drowsiness, decreased contentedness, depressed mood, difficulty concentrating, irritability, foggy/not clearheaded, flu-like symptoms, nausea/vomiting, and muscle pain/stiffness. Additional symptoms for which there was good evidence included decreased desire to socialize, unmotivated for work, decreased self-confidence, and heavy feelings in arms and legs (Juliano and Griffiths, 2004). Using a conceptual approach and findings from a prior cluster analysis (Evans and Griffiths, 1999), Juliano and Griffiths (2004) proposed a revision of caffeine withdrawal diagnostic criteria comprised of five symptom clusters. They suggested that future research with sufficient sample sizes use statistical techniques to examine the co-variation of caffeine withdrawal symptoms. Subsequently, Ozsungur et al. (2009) had caffeine consumers (N = 495) retrospectively rate the degree to which they experienced 13 symptoms validated in the Juliano and Griffiths (2004) review plus anxiety/nervousness (a symptom proposed in the DSM-IV-TR) “up to 48 h after ceasing to consume caffeine-containing beverages”. Principal components analysis (PCA) of the 14 items yielded three factors: fatigue/headache, dysphoric mood, and flu-like somatic symptoms, with difficulty concentrating loading on two of the factors. However, one important limitation of this study is its reliance on the retrospective recall, which can be subject to memory errors and systematic bias (Shiffman, 1994). Moreover, it is not clear if participants’ ratings were based on one or multiple incidents of caffeine abstinence, which is important to a meaningful analysis of clustering of symptoms during a discrete episode of caffeine withdrawal.

Prospective studies involving controlled periods of caffeine abstinence, and consistent measurement of caffeine withdrawal symptoms along with data reduction analytic strategies are needed to further our knowledge of caffeine withdrawal symptoms and their co-variation, and guide the development of DSM diagnostic criteria. In addition, a validated measure of caffeine withdrawal is needed to facilitate these objectives. Various measures have been used in prior research to assess caffeine withdrawal but have important limitations in terms of content validity and/or unknown or weak psychometric properties. For example, the Profile of Mood States (McNair et al., 1992) has been widely used in caffeine research but does not assess key features of caffeine withdrawal (e.g., headache, flu-like symptoms). In many prior studies, dozens of adjectives describing caffeine withdrawal have been individually analyzed thus increasing unreliability and the risk of Type 1 error.

To address these important gaps in research on caffeine withdrawal, we developed and administered a 23-item Caffeine Withdrawal Symptom Questionnaire (CWSQ)1 to regular caffeine consumers (N = 213) after 16 h of caffeine abstinence. PCA was conducted to reduce the 23-items to a smaller set of composite variables. To test the sensitivity of the CWSQ, ratings during caffeine abstinence were compared to ratings after double-blind caffeine administration and ratings during a typical day of caffeine consumption, but not immediately after consuming caffeine (i.e., baseline). Ratings obtained from daily and non-daily coffee consumers were also compared.

Section snippets

Participants

Participants were 213 adults (65% female, 81% Caucasian) with a mean age of 24 (SD 7.8, range 18–64 yrs) recruited from American University and the Washington, DC metropolitan area via flyers and web-based advertisements seeking coffee drinkers to participate in paid research. This sample size was chosen based on the recommendation of 10 participants per item ratio suggested for instrument analysis (DeVellis, 2003, Nunnally and Bernstein, 1994). To be eligible, participants had to consume

Principal components analysis (PCA)

Item means, standard deviations and inter-item correlations were computed and examined. Descriptive data were calculated for each item, including frequencies for each response level on the 5-point scale (0-not at all to 4-extremely). The items had inter-total correlations between .3 and .8, which are acceptable (Pett et al., 2003) indicating that items may cluster together in a subsequent PCA. Data from the 213 participants were entered into a PCA analysis. A combination of methods was used to

Discussion

A 23-item Caffeine Withdrawal Symptom Questionnaire (CWSQ) with high content validity was developed based on a rigorous review of caffeine withdrawal symptomatology (Juliano and Griffiths, 2004). Using PCA a 7-factor solution was derived that accounted for 68% of the total variance. The factors are described as follows: 1. Fatigue/drowsiness; 2. Low alertness/difficulty concentrating; 3. Mood disturbances; 4. Low sociability/motivation to work; 5. Nausea/upset stomach; 6. Flu-like feelings; and

Role of funding source

Funding for this study was provided by the College of Arts and Sciences at American University. The College had no further role in the study.

Contributors

Authors Juliano, Harrell, and Westerman contributed to the study design, subject recruitment, and running of the subjects. Authors Juliano and Huntley conducted the statistical analyses. All authors contributed to the writing of the manuscript.

Conflict of interest

No conflict declared.

Acknowledgements

We thank Sarah E. Moore and Peter G. Kardel for their assistance with this project.

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    The Caffeine Withdrawal Symptom Questionnaire appears as Supplementary Material and can be found by accessing the online version of this paper at http://dx.doi.org.

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