Psychosis intermittent hyponatremia, and polydipsia syndrome

Report
PSYCHOSIS INTERMITTENT
HYPONATREMIA, AND POLYDIPSIA
SYNDROME
นพ.วิญญู ชะนะกุล
สถาบันจิตเวชศาสตร์สมเด็จเจ้าพระยา
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
 Brain edema
 Brain herniation
ICF
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

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





 Agitation
 Irritability
Nausea/vomitting
Headache
Confusion
Delirium
Ataxia
Seizure
Coma
Death
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
hypovolemic
euvolemic
hypervolemic
• Diuretics(renal loss)
• Diarrhea (extra renal loss)
• PIP
• SIADH
• Hypothyroid
• CHF
• Cirrhosis
• Nephrotic syndrome,renal failure
Management
 Identify risk
 Multidisciplinary approach
 Biopsychosocial approach
Multidisciplinary approach
แพทย์
พยาบาล
นักจิตวิทยา
นักสังคม
• Differential diagnosis
• Treat hyponatremia,medications
• Evaluate self-care
• Water restriction,education
• Evaluate psychological function
• Behavioral intervention
• Evaluate social function
• Discharge planning,care giver
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






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
Lithium
Phenytoin
Naloxone
Propanolol
Enalapril
Clonidine
Vasopressin receptor antagonist
Clozapine
Risperidone
Behavioral approach
 Relaxation
 Stimulus control
 Self-Monitoring
 distract / substitute
 Coping skill
 Reinforcement

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