psychosis intermittent hyponatremia , and polydipsia syndrome
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PSYCHOSIS INTERMITTENT HYPONATREMIA, AND POLYDIPSIA SYNDROME
นพ. วญิญู ชะนะกลุสถาบนัจติเวชศาสตรส์มเด็จเจา้พระยา
Outline
Definition Prevalence Etiology Diagnosis Management
Definition
Polydipsia Primary /psychogenic polydipsia Secondary------DI,DM,medications
Hyponatremia
Water intoxication
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
Normal adaptaion
Thirst center
AVP (ADH)
Brain volume regulation
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
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
Signs and symptoms
Simple polydipsia with polyuria water seeking behavior
Polydipsia with water intoxication ( hyponatremic encephalopathy )
Signs and symptoms
Somatic symptoms Psychiatric symptoms Nausea/vomitting Headache Confusion Delirium Ataxia Seizure Coma Death
Agitation Irritability
Signs and symptoms
Chronic hyponatremia
ataxia/ fall
subtle cognitive impairment
diagnosis
No diagnostic standard
Measurement
Biological measure Urine specific gravity Diurnal weight gain Urine osmolarity
Behavioral measure
Differential diagnosis
•Diuretics(renal loss)•Diarrhea (extra renal
loss)
hypovolemic
•PIP•SIADH•Hypothyroid
euvolemic
•CHF•Cirrhosis•Nephrotic syndrome,renal
failure
hypervolemic
Management
Identify risk Multidisciplinary approach Biopsychosocial approach
Multidisciplinary approach
•Differential diagnosis•Treat
hyponatremia,medications
แพทย์
•Evaluate self-care•Water restriction,educationพยาบาล
•Evaluate psychological function
•Behavioral interventionนักจติวทิยา
•Evaluate social function•Discharge planning,care
giverนักสงัคม
Treatment
Acute treatment
Long-term treatment
Acute treatment
Water restriction Increase renal free-water excretion Na+ replacement Supportive treatment Symptomatic treatment
Acute treatment
Fluid restriction Diuretics Salines -- 3%NaCl
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
Behavioral approach
Relaxation Stimulus control Self-Monitoring
distract / substitute Coping skill Reinforcement
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