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

Outline Definition Prevalence Etiology Diagnosis Management

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

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

Normal adaptaion Thirst center AVP (ADH) Brain volume regulation Normal patient can excrete water 10-15 l/day แต่จิตเวช compensate ไม่ไหว เพราะ กินน้ำมากก//// SIADH

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 ไม่ได้เกิดจาก delusion,hallucination

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 Normal patient can excrete water 10-15 l/day แต่จิตเวช compensate ไม่ไหว เพราะ กินน้ำมากก//// SIADH

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

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…….

Signs and symptoms Chronic hyponatremia ataxia/ fall subtle cognitive impairment

diagnosis No diagnostic standard

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

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

Management Identify risk Multidisciplinary approach Biopsychosocial approach

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

Treatment Acute treatment Long-term treatment

Do not more than 8 mmol/day

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

Acute treatment Fluid restriction Diuretics Salines -- 3%NaCl 3%nacl 200-300ml in 3-4 hr

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 Lithium ------nephrogenic DI = renal resist to ADH

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