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

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
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