Psychosis intermittent hyponatremia , and polydipsia syndrome

1. นพ.วิญญู ชะนะกุล สถาบันจิตเวชศาสตร์สมเด็จเจ้าพระยา Psychosis intermittent hyponatremia, and polydipsia syndrome

2. Outline • Definition • Prevalence • Etiology • Diagnosis • Management

3. Definition • Polydipsia • Primary /psychogenic polydipsia • Secondary------DI,DM,medications • Hyponatremia • Water intoxication

4. Hyponatremia • Plasma Na+ below 135 mMol/L

5. Water intoxication • = SYMPTOMATIC HYPONATREMIA

6. Water intoxication • Diarrhea-------hypotonic rehydration • Marathon runners • Drinking contest • Iatrogenic • PIP

7. polydipsia hyponatremia Water intoxication

8. Psychosis intermittent hyponatremia, and polydipsia syndrome • Compulsive water drinking • Psychogenic polydipsia • Self-induced water intoxication • Without any organic disease • Normal renal function

9. Prevalence • 3-40 % in chronic psychiatric inpatients • 80 % are schizophrenia • 10 % are organic mental disorder • 5 % had episodes of water intoxication

10. Normal adaptaion • Thirst center • AVP (ADH) • Brain volume regulation

11. Etiology • Hypothalamic defect • Abnormal regulation of thirst • +- SIADH

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

13. Risk of water intoxication in polydipsic patients • Rapidity • Severity

14. Pathophysiology • Polydipsia • Decrease plasma osmolality • ECF ICF • Brain edema • Brain herniation

17. Abnormal adaptaion • Thirst center +- AVP (ADH) • Brain volume regulation

18. Signs and symptoms • Simplepolydipsiawith polyuria • water seeking behavior • Polydipsia with water intoxication ( hyponatremic encephalopathy )

19. Signs and symptoms Somatic symptoms Psychiatric symptoms • Nausea/vomitting • Headache • Confusion • Delirium • Ataxia • Seizure • Coma • Death • Agitation • Irritability

20. Signs and symptoms • Chronic hyponatremia • ataxia/ fall • subtle cognitive impairment

21. diagnosis • No diagnostic standard

22. Measurement • Biological measure • Urine specific gravity • Diurnal weight gain • Urine osmolarity • Behavioral measure

23. Differential diagnosis

24. Management • Identify risk • Multidisciplinary approach • Biopsychosocial approach

25. Multidisciplinary approach

26. Treatment • Acute treatment • Long-term treatment

28. Acute treatment • Water restriction • Increase renal free-water excretion • Na+ replacement • Supportive treatment • Symptomatic treatment

29. Acute treatment • Fluid restriction • Diuretics • Salines -- 3%NaCl

30. Goal of acute treatment • 1. symptoms are abolished • 2. safe plasma Na+ ( > 120mmol/l) • 3. not more than 10-12 mmol/l/day

31. Long-term treatment • Salt -added diet • Medications • Voluntary water restraint • Involuntary water restriction

32. Medications • Lithium • Phenytoin • Naloxone • Propanolol • Enalapril • Clonidine • Vasopressin receptor antagonist • Clozapine • Risperidone

33. Behavioral approach • Relaxation • Stimulus control • Self-Monitoring • distract / substitute • Coping skill • Reinforcement