PSYCHOSIS INTERMITTENT HYPONATREMIA, AND POLYDIPSIA SYNDROME

นพ. วญิญู ชะนะกลุสถาบนัจติเวชศาสตรส์มเด็จเจา้พระยา

Outline

Definition Prevalence Etiology Diagnosis Management

Definition

Polydipsia Primary /psychogenic polydipsia Secondary------DI,DM,medications

Hyponatremia

Water intoxication

Hyponatremia

Plasma Na+ below 135 mMol/L

Water intoxication

= SYMPTOMATIC HYPONATREMIA

Water intoxication

Diarrhea-------hypotonic rehydration Marathon runners Drinking contest Iatrogenic PIP

polydipsia

hyponatremia

Water intoxication

Psychosis intermittent hyponatremia, and polydipsia syndrome

Compulsive water drinking Psychogenic polydipsia Self-induced water intoxication Without any organic disease Normal renal function

Prevalence

3-40 % in chronic psychiatric inpatients

80 % are schizophrenia 10 % are organic mental disorder 5 % had episodes of water

intoxication

Normal adaptaion

Thirst center

AVP (ADH)

Brain volume regulation

Etiology

Hypothalamic defect Abnormal regulation of thirst +- SIADH

Associated factors Male gender Caucasian Schizophrenia /mental retardation Chronicity of psychiatric disorder Negative symptoms Disorganized symptoms General symptoms of psychopathology Smoking

Risk of water intoxication in polydipsic patients Rapidity

Severity

Pathophysiology

Polydipsia Decrease plasma osmolality ECF ICF Brain edema Brain herniation

Abnormal adaptaion

Thirst center

+- AVP (ADH)

Brain volume regulation

Signs and symptoms

Simple polydipsia with polyuria water seeking behavior

Polydipsia with water intoxication ( hyponatremic encephalopathy )

Signs and symptoms

Somatic symptoms Psychiatric symptoms Nausea/vomitting Headache Confusion Delirium Ataxia Seizure Coma Death

Agitation Irritability

Signs and symptoms

Chronic hyponatremia

ataxia/ fall

subtle cognitive impairment

diagnosis

No diagnostic standard

Measurement

Biological measure Urine specific gravity Diurnal weight gain Urine osmolarity

Behavioral measure

Differential diagnosis

•Diuretics(renal loss)•Diarrhea (extra renal

loss)

hypovolemic

•PIP•SIADH•Hypothyroid

euvolemic

•CHF•Cirrhosis•Nephrotic syndrome,renal

failure

hypervolemic

Management

Identify risk Multidisciplinary approach Biopsychosocial approach

Multidisciplinary approach

•Differential diagnosis•Treat

hyponatremia,medications

แพทย์

•Evaluate self-care•Water restriction,educationพยาบาล

•Evaluate psychological function

•Behavioral interventionนักจติวทิยา

•Evaluate social function•Discharge planning,care

giverนักสงัคม

Treatment

Acute treatment

Long-term treatment

Acute treatment

Water restriction Increase renal free-water excretion Na+ replacement Supportive treatment Symptomatic treatment

Acute treatment

Fluid restriction Diuretics Salines -- 3%NaCl

Goal of acute treatment

1. symptoms are abolished

2. safe plasma Na+ ( > 120mmol/l)

3. not more than 10-12 mmol/l/day

Long-term treatment

Salt -added diet Medications Voluntary water restraint Involuntary water restriction

Medications

Lithium Phenytoin Naloxone Propanolol Enalapril Clonidine Vasopressin receptor antagonist Clozapine Risperidone

Behavioral approach

Relaxation Stimulus control Self-Monitoring

distract / substitute Coping skill Reinforcement