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Psychosis intermittent hyponatremia, and polydipsia syndrome
นพ.วิญญู ชะนะกุล สถาบันจิตเวชศาสตร์สมเด็จเจ้าพระยา
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Outline Definition Prevalence Etiology Diagnosis Management
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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
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Hyponatremia Plasma Na+ below 135 mMol/L
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Water intoxication = SYMPTOMATIC HYPONATREMIA
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Water intoxication Diarrhea-------hypotonic rehydration
Marathon runners Drinking contest Iatrogenic PIP
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polydipsia hyponatremia Water intoxication
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Psychosis intermittent hyponatremia, and polydipsia syndrome
Compulsive water drinking Psychogenic polydipsia Self-induced water intoxication Without any organic disease Normal renal function
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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
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Normal adaptaion Thirst center AVP (ADH) Brain volume regulation
Normal patient can excrete water l/day แต่จิตเวช compensate ไม่ไหว เพราะ กินน้ำมากก//// SIADH
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Etiology Hypothalamic defect Abnormal regulation of thirst +- SIADH
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Associated factors Male gender Caucasian
Schizophrenia /mental retardation Chronicity of psychiatric disorder Negative symptoms Disorganized symptoms General symptoms of psychopathology Smoking ไม่ได้เกิดจาก delusion,hallucination
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Risk of water intoxication in polydipsic patients
Rapidity Severity
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Pathophysiology Polydipsia Decrease plasma osmolality ECF ICF
Brain edema Brain herniation
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Abnormal adaptaion Thirst center +- AVP (ADH) Brain volume regulation
Normal patient can excrete water l/day แต่จิตเวช compensate ไม่ไหว เพราะ กินน้ำมากก//// SIADH
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Signs and symptoms Simple polydipsia with polyuria
water seeking behavior Polydipsia with water intoxication ( hyponatremic encephalopathy )
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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…….
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Signs and symptoms Chronic hyponatremia ataxia/ fall
subtle cognitive impairment
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diagnosis No diagnostic standard
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Measurement Biological measure Behavioral measure
Urine specific gravity Diurnal weight gain Urine osmolarity Behavioral measure เหตุผลที่ต้องหาตัววัดเพราะจะวัด fluid intake ตลอดเวลาไม่ได้////////Specific gravity most sensitive
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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
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Management Identify risk Multidisciplinary approach Biopsychosocial approach
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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
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Treatment Acute treatment Long-term treatment
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Do not more than 8 mmol/day
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Acute treatment Water restriction Increase renal free-water excretion
Na+ replacement Supportive treatment Symptomatic treatment
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Acute treatment Fluid restriction Diuretics Salines -- 3%NaCl
3%nacl ml in 3-4 hr
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Goal of acute treatment
1. symptoms are abolished 2. safe plasma Na+ ( > 120mmol/l) 3. not more than mmol/l/day
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Long-term treatment Salt -added diet Medications
Voluntary water restraint Involuntary water restriction
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Medications Lithium Phenytoin Naloxone Propanolol Enalapril Clonidine
Vasopressin receptor antagonist Clozapine Risperidone Lithium nephrogenic DI = renal resist to ADH
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Behavioral approach Relaxation Stimulus control Self-Monitoring
distract / substitute Coping skill Reinforcement
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