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นพ. วิญญู ชะนะกุล สถาบันจิตเวชศาสตร์สมเด็จเจ้าพระยา.

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Presentation on theme: "นพ. วิญญู ชะนะกุล สถาบันจิตเวชศาสตร์สมเด็จเจ้าพระยา."— Presentation transcript:

1 นพ. วิญญู ชะนะกุล สถาบันจิตเวชศาสตร์สมเด็จเจ้าพระยา

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

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

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

19 Signs and symptoms Somatic symptomsPsychiatric 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 Diuretics(renal loss) Diarrhea (extra renal loss) hypovolemic PIP SIADH Hypothyroid euvolemic CHF Cirrhosis Nephrotic syndrome,renal failure hypervolemic

24 Management  Identify risk  Multidisciplinary approach  Biopsychosocial approach

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

26 Treatment  Acute treatment  Long-term treatment

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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 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


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