Vieweg Wv

Treatment of psychosis, intermittent hyponatremia, and polydipsia (PIP Syndrome) using lithium and phenytoin

Six patients [5 men and 1 woman, mean age 37.3 +/- 8.2 (SD) years] with psychosis, intermittent hyponatremia, and polydipsia (PIP syndrome) underwent a sequence of treatments in an effort to normalize basal serum sodium levels and thereby protect the patients against complications, including hyponatremic seizures and coma. The morning baseline group mean basal serum sodium value was 132.5 +/- 3.8 meq/liter. Over a 20-month period, the sequence of treatments was salt-added diet, lithium and phenytoin, and lithium alone. Each treatment program yielded morning group mean basal serum sodium determinations superior to baseline values, except for the program of lithium alone, which could not be tolerated. The combination of lithium and phenytoin provided a morning group mean basal serum sodium level of 140.6 +/- 3.2 meq/liter, which was superior (p less than 0.01) to all other treatment modalities. Early morning hyposthenuria persisted throughout the 20-month period of observation.

Diurnal variation of urinary excretion for patients with psychosis, intermittent hyponatremia, and polydipsia (PIP syndrome)

Ten patients [8 men and 2 women, mean age (SD) 37.6 +/- 6.5 years] with psychosis, intermittent hyponatremia, and polydipsia (PIP syndrome) underwent serial determinations at 6:00 AM, 12 noon, 6:00 PM, and 12 midnight of levels of urinary creatinine concentration (UCR), urinary specific gravity (SPGR), and urinary osmolality (UOSM) on 8 consecutive Thursdays. Diurnal variation (p less than 0.015) was present in the case of each parameter of urinary excretion (UCR, SPGR, and UOSM). These three parameters remained very low throughout the day (mean UCR 19.0 mg/dl, mean SPGR 1.0033, and mean UOSM 112.6 mosmol/kg), which is consistent with severe and persistent hyposthenuria, and each parameter correlated well with the other two parameters (r between 0.78 and 0.93, p less than 0.001). The 6:00 PM (UC6PM) value for UCR correlated best with the daily mean UCR (UCM), providing the simple linear regression UCM = 0.7615 X UC6PM + 6.1503 (r = 0.912, p = 0.0005) for the 10 PIP patients. Twenty-four-hour urinary volume (24UV) could then be estimated using UCM and values of 17.5 and 12.5 mg creatinine/kg body weight for male and female PIP patients, respectively, to calculate the daily urinary excretion of urinary creatinine. The group mean 24UV was 6963 ml, with a range of 4934-9884 ml. We hope that information about the diurnal variation of urinary excretion (21.6%, 20.5%, 27.4%, and 30.4% of 24UV excreted in consecutive quartiles commencing with the 12 midnight to 6:00 AM quartile), coupled with the utilization of the equation UCM = 0.7615 X UC6PM + 6.1503 (r = 0.912, p = 0.0005) to estimate UCM as an index of 24UV in the PIP syndrome, will provide tools to better elucidate the relationship between psychosis and water dysregulation.

Diurnal variation of sodium and water metabolism among patients with psychosis, intermittent hyponatremia, and polydipsia (PIP syndrome)

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The “Mini-Mental State” Examination in the Syndrome of Self-Induced Water Intoxication and Schizophrenic Disorders (SIWIS): A Pilot Study

A quantitative assessment of cognitive state (Folsteins “mini-mental state” scores) was correlated with serum sodium concentration in four patients with the syndrome of self-induced water intoxication and schizophrenic disorders (SIWIS). Diagnostic studies that demonstrated inappropriate antidiuresis in these patients are reported also. Neither absolute serum sodium concentrations nor their daily changes correlated significantly (p > .05) with the cognitive state of any patient. The authors conclude that serial laboratory determinations of serum electrolytes remains the only satisfactory method of monitoring body tonicity in SIWIS patients.

Development of water dysregulation during arieti's third stage of schizophrenia?

We found abnormal diurnal weight gain among 25% of acutely psychotic patients with schizophrenia and 68% of chronically psychotic patients with schizophrenia. They were weighed at 7:00 AM and 4:00 PM weekly for 3 weeks. We normalized the diurnal weight gain (NDWG) as a percentage by subtracting the 7:00 AM weight from the 4:00 PM weight, multiplying the difference by 100, and dividing the result by the 7:00 AM weight, NDWG was 0.93% +/- 0.89% for the 36 acutely psychotic patients and 2.2% +/- 1.5% for the 68 chronically psychotic patients (F = 25.297, p less than 0.0001). Drugs did not explain this difference. Our data, though preliminary, suggest that water dysregulation, as manifested by abnormal diurnal weight gain, develops in schizophrenia as patients progress into Arietis third stage of this disorder. A longitudinal study design, rather than our cross-sectional one, would be necessary to assess developmental changes in schizophrenia.

Increase in white blood cell count and serum sodium level following the addition of lithium to carbamazephine treatment among three chronically psychotic male patients with disturbed affective states

Three male chronically psychotic patients (mean age 33.0±S.D. 7.2 years), two with schizoaffective disorder and one with organic affective disorder, received carbamazepine (CBZ) because of affective symptoms (and, in one case, partial complex seizures) refractory to management with antipsychotic drugs. Coincident with CBZ administration (and clinical improvement), hyponatremia developed thought to be due to the antidiuretic effect of this drug. Lithium was added to counteract the antidiuretic effect of CBZ. Further clinical improvement ensured, serum sodium levels became normal, and there was an increase in the white blood cell count in each patient. The clinical implications of our findings are discussed.

Grades 1 and 2 hypothyroidism in a state mental hospital: risk factors and clinical findings.

Thirty-six chronically psychotic patients (nine men and 27 women, mean age 56.7+/−S.D. 13.4 years) were found to have elevated thyroid stimulating hormone (TSH) levels during review of thyroid function screening tests of 1150 patients over a 15 month period in a 700 bed state mental hospital. This study population of 36 patients was more likely to be female and older than the general hospital population. The spectrum and frequency of psychiatric diagnoses included dementia (3); schizoaffective disorder (12); bipolar disorder (6); schizophrenic disorder (4); organic affective disorder (7); major depression (3); and mental retardation (1). Only nine of these 36 patients failed to receive the goitrogens lithium (LI), carbamazepine (CBZ) and/or phenytoin (PTN) and five of those nine patients had a history of thyroid disease. Sex did not predict age, thyroxine (T4) level, triiodothyronine (T3) uptake, or TSH. The distribution of psychiatric diagnoses were the same for both sexes. Expectedly, there was an inverse relationship between TSH and T4 and T3 uptake. Using T4 to separate grades 1 and 2 hypothyroidism revealed that six (17%) patients had grade 1 disease. Men were more likely to have a seizure disorder and receive LI, CBZ, and PTN. Women were more likely to have a history of thyroid disease. The goitrogenic effects of LI+CBZ seemed additive compared with patients receiving LI alone. While T4, T3 uptake, and LI levels were the same for the two groups, patients receiving LI+CBZ had higher TSH values (p=0.028) than did patients receiving LI alone. A history of thyroid disease did not alter T4 or T3 uptake but was associated with a higher TSH (p=0.039). The clinical implications of our findings are discussed.

Abnormal diurnal weight gain among chronically psychotic patients contrasted with acutely psychotic patients and normals

We found diurnal weight gain to be abnormal among 28 institutionalized chronically psychotic patients. They were weighed daily for 15 days at 7 a.m. and 4 p.m. We normalized the diurnal weight gain (NDWG) as a percentage by subtracting the 7 a.m. weight from the 4 p.m. weight, multiplying the difference by 100, and then dividing the result by the 7 a.m. weight. NDWG was 2.8 +/- 1.3% for the 28 study patients, 0.631 +/- 0.405% for 16 acutely psychotic controls, and 0.511 +/- 0.351% for 29 normals. Ninety-three per cent of the study sample had NDWG values above the upper limit of normal. Sex, diagnosis, smoking, baseline weight, blood pressure, and pulse did not explain these observations. NDWG related (N = 28, r = 0.552, P = 0.002) to antipsychotic drug dose. The implications of our findings are discussed.