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Psychosis intermittent hyponatremia, and polydipsia syndrome

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Presentation on theme: "Psychosis intermittent hyponatremia, and polydipsia syndrome"— Presentation transcript:

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

2 Outline Definition Prevalence Etiology Diagnosis Management

3 Definition Polydipsia Hyponatremia Water intoxication
Primary /psychogenic polydipsia Secondary------DI,DM,medications Hyponatremia Water intoxication Volume,osmorality DI fluid deprivation test Medication = diuretics , anticholinergic drug

4 Hyponatremia Plasma Na+ below 135 mMol/L


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 Underestimate//////// พบในโรคอื่นได้ เช่น CNS tumor

10 Normal adaptaion Thirst center AVP (ADH) Brain volume regulation
Normal patient can excrete water l/day แต่จิตเวช compensate ไม่ไหว เพราะ กินน้ำมากก//// SIADH

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 ไม่ได้เกิดจาก delusion,hallucination

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
Normal patient can excrete water l/day แต่จิตเวช compensate ไม่ไหว เพราะ กินน้ำมากก//// SIADH

18 Signs and symptoms Simple polydipsia with polyuria
water seeking behavior Polydipsia with water intoxication ( hyponatremic encephalopathy )

19 Signs and symptoms Agitation Irritability Nausea/vomitting Headache
Somatic symptoms Psychiatric symptoms Nausea/vomitting Headache Confusion Delirium Ataxia Seizure Coma Death Agitation Irritability Early sign//// chronic sign/////death from…….

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

21 diagnosis No diagnostic standard

22 Measurement Biological measure Behavioral measure
Urine specific gravity Diurnal weight gain Urine osmolarity Behavioral measure เหตุผลที่ต้องหาตัววัดเพราะจะวัด fluid intake ตลอดเวลาไม่ได้////////Specific gravity most sensitive

23 Differential diagnosis
hypovolemic Diuretics(renal loss) Diarrhea (extra renal loss) euvolemic PIP SIADH Hypothyroid hypervolemic CHF Cirrhosis Nephrotic syndrome,renal failure แยก จากกินน้ำเยอะอื่น ได้แก่ dm,di SIADH phenothiazine,ssri,carbamazepine

24 Management Identify risk Multidisciplinary approach Biopsychosocial approach

25 Multidisciplinary approach
แพทย์ Differential diagnosis Treat hyponatremia,medications พยาบาล Evaluate self-care Water restriction,education นักจิตวิทยา Evaluate psychological function Behavioral intervention นักสังคม Evaluate social function Discharge planning,care giver

26 Treatment Acute treatment Long-term treatment

27 Do not more than 8 mmol/day

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
3%nacl ml in 3-4 hr

30 Goal of acute treatment
1. symptoms are abolished 2. safe plasma Na+ ( > 120mmol/l) 3. not more than 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 Lithium nephrogenic DI = renal resist to ADH

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

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