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Polydipsia, water intoxication, and psychiatric illness
1. Bchav. Tkrr. & Exp. Ps.vckiar. Vol. 20. No. 1, pp. 85-86. Printed in Great Britam.
oas7916/89 $3 00 + 0.00 Maxwell Pergamon Macmdlan plc.
1989
LETTER TO THE EDITOR POLYDIPSIA,
WATER INTOXICATION,
AND PSYCHIATRIC
ILLNESS
W. V. R. VIEWEG and L. S. GODLESKI Department
of Behavioral
Medicine University
and Psychiatry, & Department of Virginia, Charlottesville
Medicine,
with schizophrenia and polydipsia even though water intoxication occurs much more commonly among the latter patients. In the study under discussion, fluid intake was the dependent variable. The authors describe a very complicated (and labor intensive) paradigm to follow the fluid intake of those subject to water intoxication. It is unlikely that this procedure could be used among many such patients. We now use diurnal weight changes to follow these patients (Vieweg, Godleski, & Yank, 1987a; Vieweg et al., 1988a; Vieweg et al., 1988e). We weigh them in the morning and afternoon. We divide the difference by the morning weight to derive normalized diurnal weight gain (NDWG). When NDWG is greater than five percent (normal .5 + .35 percent, upper limit of normal 1.2 percent), we restrict access to water until we measure serum sodium. We believe our method of following body fluid shifts is easier and less expensive than that proposed by the authors. Others have used diurnal weight gain to anticipate drops in serum sodium (Koczapski et al., 1985; Koczapski et al., 1987; Delva & Crammer, 1988). In a recent study, Goldman, Luchins, and Robertson (1988) reported defects in urine dilution, osmoregulation of fluid intake, and secretion of arginine vasopressin among polydipsic, hyponatremic chronically psychotic
The paper by McNally et al. (1988) entitled “Behavioral treatment of psychogenic polydipsia”, is an important step forward in the effort to treat patients subject to the complications of water intoxication. These complications include hyponatremia, hypoosmolality, cerebral edema, delirium, psychosis, generalized seizures, coma, polyuria, bowel and bladder dilatation and hypotonicity, hydronephrosis, renal failure, congestive heart failure, and death (Vieweg et al., 1985b). Traditional treatments for such patients include fluid restriction and supplemental sodium chloride (Vieweg et al., 198%). Newer treatments include demeclocycline, lithium, and phenytoin (Goldman & Luchins, 1985; Vieweg et al., 1988b, 1988~). These drugs block the renal effects of the antidiuretic hormone, arginine vasopressin, thereby protecting the patient against dilutional hyponatremia by facilitating urinary excretion. McNally and colleagues (1988) break new ground by offering the clinicians yet another treatment for patients subject to water intoxication. This new treatment is particularly intriguing because it appears to alter the hypothalamic thirst center thought to be dysfunctional among patients subject to water intoxication (Vieweg et al., 1985a). We suspect that it was easier to get permission to use aversive conditioning in a patient with mental retardation and polydipsia than in a patient Requests for reprintsshould be addressedto W. V. R. VA 24401-1405, U.S.A.
of Internal
Vieweg,MD,
85
Western
State Hospital,
P.O.
Box 2500, Staunton,
Letter to the Editor
86
patients subject to water intoxication. We have made similar observations (Vieweg, Godleski, & Yank, 1987b; Vieweg, Robertson, Godleski, & Yank, 1988d). It appears that atria1 natriuretic peptide-induced natriuresis further exacerbates hyponatremia in this setting (Vieweg, Godleski, & Yank, 1987~; Vieweg et al., in press). These pathophysiologic findings are consistent with hypothalamic dysfunction and support the treatment approach used in the study under discussion. Extensive reviews of water dysregulation and psychosis have appeared in the literature recently (Zubenko, 1987; Illowsky & Kirch, 1988).
variation of serum sodium and ADH among patients with psychosis, intermittent hyponatremia. and polydipsia (PIP syndrome). Neuroendocrinology Leuers, 9, 219.
Vieweg, V., Godleski. L., & Yank, G. (1987~). Hyponatremia and volume expansion in psychosis. Neuroendocrinology
Letters, 9, 219.
Vieweg, W. V. R., Rowe, W. T., David, J. J., & Spradlin, W. W. (1985~). Oral sodium chloride in the management of schizophrenic patients with self-induced water intoxication. Journal of Clinical Psychiatry, 46, 16-19. Vieweg, W. V. R., Robertson, G. L., Godleski, L. S., & Yank, G. R. (1988d). Diurnal variation in water homeostasis among schizophrenic patients subject to water intoxication. Schizophrenic Research,l, 351-357. Vieweg. W. V. R., David, J. J., Rowe, W. T., Wampler, G. J., Burns, W. J., & Spradlin, W. W. (1985b). Death from self-induced water intoxication among patients with schizophrenic disorders. Journal of Nervous and Mental Disorders,
References Delva, N. J., & Crammer, J. L. (1988). Polydipsia in chronic psychiatric patients: Body weight and plasma sodium. Briksh Journal of Psychiatry, 152, 242-245. Goldman. M. B., & Luchins, D. L. (1985). Demeclocycline improves hyponatremia in chronic schizonhrenics. Bioloeical Psvchiarrv. 20, 1149-1155. G&man, M. B.: Luchins, D. J:, & Robertson, G. L. (1988). Mechanisms of altered water metabolism in psychotic patients with polydipsia and hyponatremia. New England Journal of Medicine, 318, 397-403. Illowsky, B. P., Kirch, D. G. (1988). Polydipsia and hyponatremia in psychiatric patients. American Journal of Psychiatry, IJS,
675-683.
Koczapski, A., Ibraheem. S., Paredes, J., & Ledwidge, B. (1985). Diurnal variations in hypothalamic and body weight in chronic schizophrenics with self-induced water intoxication. Journal of Clinical and lnvestigafive Medicine,
8, A86.
Koczapski, A. B., Ibraheem, S., Ashby, Y. T., Paredes, J., Jones, B. D., & Ancill. R. (1987). Early diagnosis of water intoxication by monitoring diurnal variations in bodv weight. American Journal of Psychiatry, 144.1626. McNally, R. J., Calamari, J. E:, Hansen, P. M., & Kaliher. C. (1988). Behavioral treatment of psychogenic polydipsia. jourtml of Behavior Therapy and Eiperimenral Psychiatry, 19, 57-61.
Vieweg,V., Godleski, L., & Yank, G. (1987a). Diurnal weight gain as an index of polyuria and hyponatremia among chronically psychotic patients. Neuroendocrinology
Vieweg,
V.,
Letters, 9, 218.
Godleski, L., & Yank, G. (1987b). Diurnal
173, 161-165.
Vieweg, W. V. R., Wilkinson, E. C., David, J. J., Rowe, W. T., Hobbs, W. B., Spradlin, W. W. (1988~). The use of demeclocycline in the treatment of patients with psychosis, intermittent hyponatremia, and polydipsia (PIP syndrome). Psychia& Quarterly, 59, 62-68.. Viewee. W. V. R.. Weiss. N. M.. David, J. J., Rowe, W. T., Godleski; L. S.,. & Spradlin, W. W. (1988b). Treatment of psychosis, intermittent hyponatremia, and polydipsia (PIP syndrome) using lithium and phenytoin. Biological Psychiatry, 23, 2530.
Vieweg, W. V. R., Hundley, P. L., Godleski. L. S., Tisdelle, D. A., Pruzinsky, T., & Yank, G. R. (1988e). Diurnal weight gain as a predictor of serum sodium concentration among patients with psychosis, intermittent hyponatremia, and polydipsia (PIP syndrome). Psychiatric Research,26,
305-312:
_
Vieweg, W. V. R., Carey, R. M., Godleski, L. S., Tisdelle, D. A., Pruzinsky, T., & Yank, G. R. (in press). The syndrome of psychosis, intermittent hyponatremia, and polydipsia: Evidence for diurnal volume expansion. Psychiatric Medicine Update. Vieweg, W. V.-R., David, J. J., Rowe, W. T., Peach, M. J.. Veldhuis. J. D. .‘Kaiser. D. L.. & Soradlin, W. W. (1985a). Psychogenic polydipsia and waier intoxication - concepts that have failed. Biological Psychiatry, 20, 1308-1320.
Vieweg, W. V. R., Godleski, L. S., Graham, P., Barber, J., Goldman, F., Kellogg, E., Bayliss, E. V., Glick, J., Hundley, P. L., & Yank, G. R. (1988a). Abnormal diurnal weight gain among long-term patients with schizophrenic disorders. Schizophrenia Research, I, 67-71.
Zubenko, G. S. (1987). Water homeostasis in psychiatric patients. Biological Psychiatry, 22, 121-125.
oas7916/89 $3 00 + 0.00 Maxwell Pergamon Macmdlan plc.
1989
LETTER TO THE EDITOR POLYDIPSIA,
WATER INTOXICATION,
AND PSYCHIATRIC
ILLNESS
W. V. R. VIEWEG and L. S. GODLESKI Department
of Behavioral
Medicine University
and Psychiatry, & Department of Virginia, Charlottesville
Medicine,
with schizophrenia and polydipsia even though water intoxication occurs much more commonly among the latter patients. In the study under discussion, fluid intake was the dependent variable. The authors describe a very complicated (and labor intensive) paradigm to follow the fluid intake of those subject to water intoxication. It is unlikely that this procedure could be used among many such patients. We now use diurnal weight changes to follow these patients (Vieweg, Godleski, & Yank, 1987a; Vieweg et al., 1988a; Vieweg et al., 1988e). We weigh them in the morning and afternoon. We divide the difference by the morning weight to derive normalized diurnal weight gain (NDWG). When NDWG is greater than five percent (normal .5 + .35 percent, upper limit of normal 1.2 percent), we restrict access to water until we measure serum sodium. We believe our method of following body fluid shifts is easier and less expensive than that proposed by the authors. Others have used diurnal weight gain to anticipate drops in serum sodium (Koczapski et al., 1985; Koczapski et al., 1987; Delva & Crammer, 1988). In a recent study, Goldman, Luchins, and Robertson (1988) reported defects in urine dilution, osmoregulation of fluid intake, and secretion of arginine vasopressin among polydipsic, hyponatremic chronically psychotic
The paper by McNally et al. (1988) entitled “Behavioral treatment of psychogenic polydipsia”, is an important step forward in the effort to treat patients subject to the complications of water intoxication. These complications include hyponatremia, hypoosmolality, cerebral edema, delirium, psychosis, generalized seizures, coma, polyuria, bowel and bladder dilatation and hypotonicity, hydronephrosis, renal failure, congestive heart failure, and death (Vieweg et al., 1985b). Traditional treatments for such patients include fluid restriction and supplemental sodium chloride (Vieweg et al., 198%). Newer treatments include demeclocycline, lithium, and phenytoin (Goldman & Luchins, 1985; Vieweg et al., 1988b, 1988~). These drugs block the renal effects of the antidiuretic hormone, arginine vasopressin, thereby protecting the patient against dilutional hyponatremia by facilitating urinary excretion. McNally and colleagues (1988) break new ground by offering the clinicians yet another treatment for patients subject to water intoxication. This new treatment is particularly intriguing because it appears to alter the hypothalamic thirst center thought to be dysfunctional among patients subject to water intoxication (Vieweg et al., 1985a). We suspect that it was easier to get permission to use aversive conditioning in a patient with mental retardation and polydipsia than in a patient Requests for reprintsshould be addressedto W. V. R. VA 24401-1405, U.S.A.
of Internal
Vieweg,MD,
85
Western
State Hospital,
P.O.
Box 2500, Staunton,
Letter to the Editor
86
patients subject to water intoxication. We have made similar observations (Vieweg, Godleski, & Yank, 1987b; Vieweg, Robertson, Godleski, & Yank, 1988d). It appears that atria1 natriuretic peptide-induced natriuresis further exacerbates hyponatremia in this setting (Vieweg, Godleski, & Yank, 1987~; Vieweg et al., in press). These pathophysiologic findings are consistent with hypothalamic dysfunction and support the treatment approach used in the study under discussion. Extensive reviews of water dysregulation and psychosis have appeared in the literature recently (Zubenko, 1987; Illowsky & Kirch, 1988).
variation of serum sodium and ADH among patients with psychosis, intermittent hyponatremia. and polydipsia (PIP syndrome). Neuroendocrinology Leuers, 9, 219.
Vieweg, V., Godleski. L., & Yank, G. (1987~). Hyponatremia and volume expansion in psychosis. Neuroendocrinology
Letters, 9, 219.
Vieweg, W. V. R., Rowe, W. T., David, J. J., & Spradlin, W. W. (1985~). Oral sodium chloride in the management of schizophrenic patients with self-induced water intoxication. Journal of Clinical Psychiatry, 46, 16-19. Vieweg, W. V. R., Robertson, G. L., Godleski, L. S., & Yank, G. R. (1988d). Diurnal variation in water homeostasis among schizophrenic patients subject to water intoxication. Schizophrenic Research,l, 351-357. Vieweg. W. V. R., David, J. J., Rowe, W. T., Wampler, G. J., Burns, W. J., & Spradlin, W. W. (1985b). Death from self-induced water intoxication among patients with schizophrenic disorders. Journal of Nervous and Mental Disorders,
References Delva, N. J., & Crammer, J. L. (1988). Polydipsia in chronic psychiatric patients: Body weight and plasma sodium. Briksh Journal of Psychiatry, 152, 242-245. Goldman. M. B., & Luchins, D. L. (1985). Demeclocycline improves hyponatremia in chronic schizonhrenics. Bioloeical Psvchiarrv. 20, 1149-1155. G&man, M. B.: Luchins, D. J:, & Robertson, G. L. (1988). Mechanisms of altered water metabolism in psychotic patients with polydipsia and hyponatremia. New England Journal of Medicine, 318, 397-403. Illowsky, B. P., Kirch, D. G. (1988). Polydipsia and hyponatremia in psychiatric patients. American Journal of Psychiatry, IJS,
675-683.
Koczapski, A., Ibraheem. S., Paredes, J., & Ledwidge, B. (1985). Diurnal variations in hypothalamic and body weight in chronic schizophrenics with self-induced water intoxication. Journal of Clinical and lnvestigafive Medicine,
8, A86.
Koczapski, A. B., Ibraheem, S., Ashby, Y. T., Paredes, J., Jones, B. D., & Ancill. R. (1987). Early diagnosis of water intoxication by monitoring diurnal variations in bodv weight. American Journal of Psychiatry, 144.1626. McNally, R. J., Calamari, J. E:, Hansen, P. M., & Kaliher. C. (1988). Behavioral treatment of psychogenic polydipsia. jourtml of Behavior Therapy and Eiperimenral Psychiatry, 19, 57-61.
Vieweg,V., Godleski, L., & Yank, G. (1987a). Diurnal weight gain as an index of polyuria and hyponatremia among chronically psychotic patients. Neuroendocrinology
Vieweg,
V.,
Letters, 9, 218.
Godleski, L., & Yank, G. (1987b). Diurnal
173, 161-165.
Vieweg, W. V. R., Wilkinson, E. C., David, J. J., Rowe, W. T., Hobbs, W. B., Spradlin, W. W. (1988~). The use of demeclocycline in the treatment of patients with psychosis, intermittent hyponatremia, and polydipsia (PIP syndrome). Psychia& Quarterly, 59, 62-68.. Viewee. W. V. R.. Weiss. N. M.. David, J. J., Rowe, W. T., Godleski; L. S.,. & Spradlin, W. W. (1988b). Treatment of psychosis, intermittent hyponatremia, and polydipsia (PIP syndrome) using lithium and phenytoin. Biological Psychiatry, 23, 2530.
Vieweg, W. V. R., Hundley, P. L., Godleski. L. S., Tisdelle, D. A., Pruzinsky, T., & Yank, G. R. (1988e). Diurnal weight gain as a predictor of serum sodium concentration among patients with psychosis, intermittent hyponatremia, and polydipsia (PIP syndrome). Psychiatric Research,26,
305-312:
_
Vieweg, W. V. R., Carey, R. M., Godleski, L. S., Tisdelle, D. A., Pruzinsky, T., & Yank, G. R. (in press). The syndrome of psychosis, intermittent hyponatremia, and polydipsia: Evidence for diurnal volume expansion. Psychiatric Medicine Update. Vieweg, W. V.-R., David, J. J., Rowe, W. T., Peach, M. J.. Veldhuis. J. D. .‘Kaiser. D. L.. & Soradlin, W. W. (1985a). Psychogenic polydipsia and waier intoxication - concepts that have failed. Biological Psychiatry, 20, 1308-1320.
Vieweg, W. V. R., Godleski, L. S., Graham, P., Barber, J., Goldman, F., Kellogg, E., Bayliss, E. V., Glick, J., Hundley, P. L., & Yank, G. R. (1988a). Abnormal diurnal weight gain among long-term patients with schizophrenic disorders. Schizophrenia Research, I, 67-71.
Zubenko, G. S. (1987). Water homeostasis in psychiatric patients. Biological Psychiatry, 22, 121-125.