W.T. Rowe

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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Correlation of cigarette-induced increase in serum nicotine levels with arginine vasopressin concentrations in the syndrome of self-induced water intoxication and psychosis (SIWIP)

Ten patients [9 men and 1 woman; mean age 42.4 ± 8.5 (± SD) years] who were smokers and who suffered the complications of self-induced water intoxication and psychosis (SIWIP) (8 patients with schizophrenic disorders, 1 patient with manic-depressive illness, 1 patient with dementia) are reported. Each patient underwent serial determinations of parameters of water metabolism including plasma and urine osmolality and plasma arginine vasopressin (AVP). The syndrome of inappropriate antidiuresis (SIAD) was found in each patient. Because of the reported effect that cigarette smoking has on anti-diuresis, we correlated serum nicotine (NIC) levels with plasma and urine osmolality, AVP, and 24-hour urine volume (24°-UV). We found no relationship between NIC and plasma or urine osmolality, AVP, or 24°-UV. In the presence of SIWIP and SIAD, we infer the limbic-hypothalamic neurotransmitters in these psychotic patients are sufficiently powerful in stimulating both compulsive water drinking and inappropriate release of AVP so as to overshadow any effects that NIC may have on water metabolism.

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.

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.