A 32-year-old man comes to the office due to recent insomnia. The patient has experienced stress at his job in the past month because he has had to work extra hours on multiple occasions while several coworkers have been on vacation or sick. Over the past 2 weeks, he has had difficulty falling asleep most nights and has been fatigued throughout the day. Recently, the patient has started drinking 1 or 2 beers at night to help him fall asleep as well as energy drinks throughout the day to stay alert. He describes feeling anxious and irritable and has experienced occasional palpitations and feelings of panic. The patient has a history of depression. He does not use illicit drugs. Blood pressure is 140/90 mm Hg and pulse is 95/min. On examination, the patient is restless and mildly tremulous with a flushed and agitated appearance, irritable mood, and rapid speech. Which of the following is the most likely explanation for this patient's condition?

Question

A 32-year-old man comes to the office due to recent insomnia.  The patient has experienced stress at his job in the past month because he has had to work extra hours on multiple occasions while several coworkers have been on vacation or sick.  Over the past 2 weeks, he has had difficulty falling asleep most nights and has been fatigued throughout the day.  Recently, the patient has started drinking 1 or 2 beers at night to help him fall asleep as well as energy drinks throughout the day to stay alert.  He describes feeling anxious and irritable and has experienced occasional palpitations and feelings of panic.  The patient has a history of depression.  He does not use illicit drugs.  Blood pressure is 140/90 mm Hg and pulse is 95/min.  On examination, the patient is restless and mildly tremulous with a flushed and agitated appearance, irritable mood, and rapid speech.  Which of the following is the most likely explanation for this patient's condition?

Quizplus · Accepted Answer

This patient's insomnia, anxiety, palpitations, hypertension, and tremulousness are suggestive of caffeine intoxication, likely due to his recent excessive consumption of energy drinks. Energy drinks frequently contain high quantities of caffeine and may lead to toxicity when consumed in excess. Caffeine is a stimulant that, when used excessively, can result in insomnia, jitteriness, anxiety, gastrointestinal symptoms, and headaches, as well as more serious adverse effects including tachycardia, hypertension, panic attacks, agitation, psychosis, and seizures. Energy drink consumption is especially popular among adolescents and young men, and it should be considered in anyone with signs or symptoms of stimulant intoxication. (Choices A and F) Adjustment and primary anxiety (eg, panic) disorders are diagnoses of exclusion that would not be diagnosed when symptoms are more likely to be substance-induced. (Choice B) Alcohol withdrawal can also result in anxiety, insomnia, tremulousness, hypertension, and palpitations. However, it is usually associated with heavy drinking and other signs of dependence. The amount that this patient is drinking would be very unlikely to lead to withdrawal; furthermore, his history is more consistent with caffeine intoxication from energy drinks. (Choice D) Although covering several different shifts at work could explain this patient's insomnia, it would not explain his daytime anxiety, restlessness, tremors, or palpitations, which are more consistent with caffeine intoxication. (Choice E) A hypomanic episode can include insomnia, irritability, and pressured speech, but this patient lacks other characteristic hypomanic symptoms (eg, elevated mood, increased energy, grandiosity). It would not explain this patient's prominent signs of sympathetic stimulation. Educational objective: Caffeine is a stimulant that, when used in excessive amounts, can cause sympathetic hyperactivity, leading to anxiety, jitteriness, insomnia, palpitations, and tremors. Energy drinks typically contain large amounts of caffeine and should be considered as a cause of stimulant intoxication. References: Energy drinks and their adverse health effects: a systematic review of the current evidence. (http://www.ncbi.nlm.nih.gov/pubmed/25560302) The clinical toxicology of caffeine: a review and case study. (http://www.ncbi.nlm.nih.gov/pubmed/30505695) Caffeinated energy drink consumption among adolescents and potential health consequences associated with their use: a significant public health hazard. (http://www.ncbi.nlm.nih.gov/pubmed/28845841)

A 32-Year-Old Man Comes to the Office Due to Recent