Clozapine Prescripers-Dogmatic or Pragmatic?

Clozapine, amongst antipsychotics, has a unique composite mode of action that might translate into an expanded therapeutic potential on clinical grounds. Sorely, clozapine remains underutilized.

Psychopathological characteristics in patients with arginine vasopressin deficiency (central diabetes insipidus) and primary polydipsia compared to healthy controls.

OBJECTIVE: Distinguishing arginine vasopressin deficiency (AVP-D; central diabetes insipidus) from primary polydipsia (PP), commonly referred to as psychogenic polydipsia, is challenging. Psychopathologic findings, commonly used for PP diagnosis in clinical practice, are rarely evaluated in AVP-D patients, and no comparative data between the two conditions currently exist. DESIGN: Data from two studies involving 82 participants [39 AVP-D, 28 PP, and 15 healthy controls (HC)]. METHODS: Psychological evaluations were conducted using standardized questionnaires measuring anxiety [State-Trait Anxiety Inventory (STAI)], alexithymia [Toronto Alexithymia Scale (TAS-20)], depressive symptoms (Beck's Depression Inventory-II (BDI-II), and overall mental health [Short Form-36 Health Survey (SF-36)]. Higher STAI, TAS-20, and BDI-II scores suggest elevated anxiety, alexithymia, and depression, while higher SF-36 scores signify better overall mental health. RESULTS: Compared to HC, patients with AVP-D and PP showed higher levels of anxiety (HC 28 points [24-31] vs AVP-D 36 points [31-45]; vs PP 38 points [33-46], P < .01), alexithymia (HC 30 points [29-37] vs AVP-D 43 points [35-54]; vs PP 46 points [37-55], P < .01), and depression (HC 1 point [0-2] vs AVP-D 7 points [4-14]; vs PP 7 points [3-13], P < .01). Levels of anxiety, alexithymia, and depression showed no difference between both patient groups (P = .58, P = .90, P = .50, respectively). Compared to HC, patients with AVP-D and PP reported similarly reduced self-reported overall mental health scores (HC 84 [68-88] vs AVP-D 60 [52-80], P = .05; vs PP 60 [47-74], P < .01). CONCLUSION: This study reveals heightened anxiety, alexithymia, depression, and diminished overall mental health in patients with AVP-D and PP. The results emphasize the need for careful interpretation of psychopathological characteristics to differentiate between AVP-D and PP.

Treatment of Psychogenic Polydipsia and Hyponatremia: A Case Report.

Psychogenic polydipsia occurs during water or fluid intoxication and can lead to electrolyte disturbances, such as hyponatremia. Hyponatremia can give rise to signs and symptoms, including lethargy, psychosis, seizures, or death. Psychogenic, or primary polydipsia, can be compared to other medical conditions that cause excessive thirst. This case report will focus on the symptoms, disease, and treatment involved in the care and hospitalization of a 30-year-old male patient who reported ingesting up to 40 liters of water a day for the last three years. This patient with psychogenic polydipsia, chronic schizophrenia, and active psychosis was diagnosed with metabolic encephalopathy secondary to severe hyponatremia (day one sodium level: 108 mEq/L). The management goal was to stabilize electrolytes and increase sodium levels without causing osmotic demyelination syndrome. During subsequent hospitalization, the psychiatry team worked towards the normalization of sodium levels and managed behavioral patterns contributing to water consumption. The patient achieved a normal sodium level on day 21 of inpatient psychiatric treatment with the following medication regimen: acetazolamide, candesartan, olanzapine, sodium chloride, and trazodone.

The Catastrophic Effects of Psychogenic Polydipsia: A Case Report.

Patients with hyponatremia are at risk of severe complications including seizures, coma, and death. Psychiatric patients are particularly susceptible to death from hyponatremia due to the association between psychiatric conditions and psychogenic polydipsia, characterized by water intoxication. We report a case of a schizophrenic patient who presented with altered mental status, leading to a differential diagnosis narrowed through clinical investigations to include hypovolemic hyponatremia, syndrome of inappropriate antidiuretic hormone secretion (SIADH), and psychogenic polydipsia. This case underscores the need to inquire about schizophrenic patients' water intake, advocating for a standardized approach. The timely diagnosis of disorders causing electrolyte abnormalities can prevent severe complications and aid in the management of psychiatric patients.

Hyponatremia-Induced Seizure in a Patient With Psychogenic Polydipsia: A Case Report.

Psychogenic polydipsia is a rare condition characterized by overconsumption of water. It can lead to water intoxication, which is potentially a life-threatening situation. Moreover, it usually occurs in patients with mental disorders, mainly schizophrenia. This report discusses a successful treatment of a 16-year-old male with psychogenic polydipsia and delusional disorder presenting to the emergency room with a hyponatremia-induced seizure. After stabilizing the patient, he was referred to a psychologist, and behavioral therapy was conducted. Post-discharge follow-ups revealed that behavioral therapy and the use of self-monitoring technique were effective in controlling the patient's condition. His water intake was reduced from 15 liters per day to three liters per day. This case highlights the importance of psychological assessment for patients with features suggestive of psychogenic polydipsia. It also highlights the need for immediate admission and prompt treatment for such patients as it is a high-risk condition.

RHABDOMYOLYSIS SECONDARY TO RAPID CORRECTION OF HYPONATREMIA IN A PATIENT WITH PSYHCOGENIC POLYDIPSIA.

Patients with chronic schizophrenia and psychosis are more prone to develop hyponatremia. Hyponatremia could be due to medications e.g. antidepressants/antipsychotics or secondary to psychogenic polydipsia. They often present with altered consciousness, seizures and falls. Rapid correction of hyponatremia in patients with psychogenic polydipsia has been associated to cause rhabdomyolysis, an under-recognized yet serious condition which if left untreated can result in various complications e.g. acute kidney injury, electrolyte abnormalities. We report a case of young patient who had background illness of schizophrenia and presented to department with severe hyponatremia secondary to psychogenic polydipsia and was eventually diagnosed as case of rhabdomyolysis due to rapid correction of hyponatremia. Objective of case report is to highlight the correct diagnosis of underlying cause of hyponatremia and challenges associated with managing rhabdomyolysis with IV fluids that can result in worsening of hyponatremia, hence emphasizing the importance of close monitoring of sodium levels and measurement of creatine kinase in any patient who presents with severe hyponatremia, particularly in the presence of other risk factors for rhabdomyolysis and consideration of careful fluid administration strategies in relation to the relative onset and risk of over-correcting hyponatremia.

A Rare Case of Coexisting Psychogenic Polydipsia and Nephrogenic Diabetes Insipidus With Lithium Therapy.

Lithium is a commonly used medication for mood stabilization and a well-known cause of nephrogenic diabetes insipidus (DI). Coexistent psychogenic polydipsia with nephrogenic DI is uncommon, and its management is challenging due to the wide variation in serum sodium based on fluctuations in water intake. Here, we describe the case of a 56-year-old male with psychogenic polydipsia and nephrogenic DI which manifested in wide swings of serum sodium over a short interval. He initially presented with hyponatremia with low urine osmolality consistent with psychogenic polydipsia. His serum sodium began to improve after free water restriction. However, later in the course, he developed an increase in serum sodium levels and polyuria with persistent low urine osmolality consistent with DI.

Non-antipsychotic pharmacotherapy of psychogenic polydipsia: A systematic review.

OBJECTIVE: Polydipsia is defined at the intake of excessive fluid (>3 L daily). Psychogenic polydipsia (PPD) presents without an identifiable medical cause and is often seen in patients with diagnoses of schizophrenia, OCD, anxiety, alcohol use disorder, and other psychotic disorders. The purpose of this systematic review is to assess the therapeutic effect of various non-antipsychotic medications on patients with a stable psychotic illness and concurrent PPD. METHODS: A systematic search was conducted using the following databases: PubMed, MEDLINE with Full Text, CINAHL complete, Cochrane database of systematic reviews, Cochrane methodology register, MasterFILE Premier, APA PsychArticles, APA PsychInfo, APA PsycBooks, APA PsycTests, TRIP, Nursing and Allied Health. The quality of each retained study was assessed using appropriate risk of bias tools based on study design. RESULTS: The initial search resulted in 1422 articles from which 22 articles were included for qualitative synthesis. Study designs ranged from case reports to double blind, placebo controlled randomized trials and was interpreted uniquely based on study design. Acetazolamide was effective in improving some PPD outcomes. Fluoxetine at high doses was effective in reducing fluid intake and polydipsia. Other medications included in this review performed equivocally for reduction of numerous parameters evaluating PPD. CONCLUSION: No one drug appeared to be the most efficacious; however, some did show promise in specific populations. Those in need of pharmacotherapeutic options for PPD may consider one of the included agents to assist with co-morbid state. Further high-quality research is needed to provide better treatment guidance for PPD.

Polidipsia psicógena e hiponatremia severa en trastorno afectivo bipolar: informe de caso / Psychogenic polydipsia and severe hyponatremia in bipolar affective disorder: case report

La polidipsia psicógena, polidipsia primaria o potomaníaes un trastorno de origen multifactorial que se asocia con unamorbilidad y mortalidad sustancial. Se presenta frecuentemente en pacientes con enfermedades psiquiátricas, particularmente aquellos con esquizofrenia, sin embargo, no es exclusiva de esta, ya que se ha notificado en menor proporción enpacientes con trastornos de ansiedad y trastornos del estadode ánimo. Peso a todo lo anterior, continúa siendo una afección poco comprendida y por ende subdiagnosticada.Es fundamental reconocer esta entidad clínica de manera oportuna, debido a sus complicaciones potencialmentegraves como la hiponatremia sintomática que puede derivaren coma y muerte si no se detecta y se maneja tempranamente. Además, se debe recalcar la importancia de una elección acertada de los psicofármacos, ya que la mayoría delos estabilizantes del afecto y algunos inhibidores selectivosde la recaptación de serotonina, pueden causar y/o agravardicho trastorno hidroelectrolítico, lo cual implica un desafíoadicional para el especialista al momento de establecer laterapia de mantenimiento.Son escasos los reportes en la literatura sobre polidipsiapsicógena documentada en trastornos del estado de ánimo,con este propósito, exponemos el caso de una paciente contrastorno afectivo bipolar que desarrolló hiponatremia severa secundaria a polidipsia primaria. (AU)

Psychogenic polydipsia, primary polydipsia or potomaniais a disorder of multifactorial etiology which is associatedwith substantial morbidity and mortality. It occurs frequently in patients with psychiatric diseases, particularly thosewith schizophrenia, however, it is not exclusive, it has beenreported in a lower proportion in patients with anxiety disorders and mood disorders. Although, is still poorly understoodand therefore underdiagnosed condition.It is essential to recognize this clinical entity opportunely,due to its potentially serious complications, such as symptomatic hyponatremia that can lead to coma and death if notdetected and managed early. Furthermore, the importanceof a correct choice of psychotropic medications should beemphasized, since most of the mood stabilizers and someselective serotonin reuptake inhibitors can cause and / oraggravate the hydroelectrolytic disorder, which implies anadditional challenge for the specialist in establishing maintenance therapy.There are few reports in the literature on documentedpsychogenic polydipsia in mood disorders, for this purpose, we present the case of a patient with bipolar affectivedisorder suffering from severe hyponatremia secondary toprimary polydipsia. (AU)

Catatonia Associated with Hyponatremia: Case Report and Brief Review of the Literature.

BACKGROUND: Catatonia is a syndrome of altered motor behavior that is mostly associated with general medical, neurologic, mood and schizophrenia-spectrum disorders. The association of newly onset catatonic symptoms with hyponatremia has been rarely reported in the literature. CASE PRESENTATION: We present a rare case of a young female patient with schizophrenia, who presented with catatonic symptoms in the context of hyponatremia due to water intoxication. The symptoms were eliminated with the correction of hyponatremia. There are only a few reports of hyponatremia-associated catatonia in psychiatric and non-psychiatric patients. Sometimes, catatonic symptoms may co-occur with newly onset psychotic symptoms and confusion, suggesting delirium. In several cases, the catatonic symptoms responded to specific treatment with benzodiazepines or electroconvulsive therapy. CONCLUSION: Hyponatremia may induce catatonic symptoms in patients, regardless of underlying mental illness, but this phenomenon is even more relevant in patients with a psychotic or mood disorder, which may itself cause catatonic symptoms. It is important for clinicians not to attribute newly-onset catatonic symptoms to the underlying psychotic or mood disorder without measuring sodium serum levels. The measurement of sodium serum levels may guide treating psychiatrists to refer the patient for further investigation and appropriate treatment.

Primary polydipsia: Update.

In primary polydipsia pathologically high levels of water intake physiologically lower arginine vasopressin (AVP) secretion, and in this way mirror the secondary polydipsia in diabetes insipidus in which pathologically low levels of AVP (or renal responsiveness to AVP) physiologically increase water intake. Primary polydipsia covers several disorders whose clinical features and significance, risk factors, pathophysiology and treatment are reviewed here. While groupings may appear somewhat arbitrary, they are associated with distinct alterations in physiologic parameters of water balance. The polydipsia is typically unrelated to homeostatic regulation of water intake, but instead reflects non-homeostatic influences. Recent technological advances, summarized here, have disentangled functional neurocircuits underlying both homeostatic and non-homeostatic physiologic influences, which provides an opportunity to better define the mechanisms of the disorders. We summarize this recent literature, highlighting hypothalamic circuitry that appears most clearly positioned to contribute to primary polydipsia. The life-threatening water imbalance in psychotic disorders is caused by an anterior hippocampal induced stress-diathesis that can be reproduced in animal models, and involves phylogenetically preserved pathways that appear likely to include one or more of these circuits. Ongoing translational neuroscience studies in these animal models may potentially localize reversible pathological changes which contribute to both the water imbalance and psychotic disorder.

Olanzapine-Induced Hyponatremia Presenting with Seizure Requiring Intensive Care Unit Admission.

Rapid-onset hyponatremia is a rare, but potential, complication of olanzapine treatment. Hyponatremia, secondary to atypical antipsychotic use, has been reported in many case reports and is thought to be associated with a syndrome of inappropriate anti-diuretic hormone secretion (SIADH). Psychogenic polydipsia is a separate cause of hyponatremia, which is also seen in the psychiatric population, particularly in schizophrenia, and must be differentiated from SIADH. We report a case of sudden-onset hyponatremia resulting in seizure onset necessitating intensive care unit admission in a patient taking olanzapine during hospitalization in a psychiatric unit. Clinicians should be aware of the association between olanzapine and hyponatremia secondary to SIADH or psychogenic polydipsia. As in our case, the patient status may decline rapidly, resulting in seizure onset. Physicians should actively monitor patients taking antipsychotics for changes in serum sodium levels.

A Case of Unrecognized Psychogenic Polydipsia

@#Psychogenic polydipsia is prevalent among people with schizophrenia. Although its pathophysiology is relatively unknown, it causes life threatening complications due to acute or severe hyponatraemia.. This report illustrates a patient with schizophrenia who had unrecognized psychogenic polydipsia and developed severe complication. It also highlights the clinical salience of its management.

Role of Naltrexone in Improving Compulsive Drinking in Psychogenic Polydipsia.

Psychogenic polydipsia or self-induced water intoxication is a potentially lethal condition seen in many chronic psychiatric patients. This is a literature review based on therapeutic significance of Naltrexone in improving compulsive water drinking behavior in chronic psychiatrically ill patients with psychogenic polydipsia. Naltrexone is an opioid antagonist approved by FDA for alcohol dependence. Extensive literature search provides a line of evidence that suggests correlation of opioid receptor with compulsive water ingestion in animals. However, there is limited data regarding clinical utility of naltrexone in improving psychogenic polydipsia in human species. This review highlights the necessity for further research and trials to elucidate the role of naltrexone in human psychogenic drinking behavior.

Acute Dysnatremias - a dangerous and overlooked clinical problem.

BACKGROUND: Dysnatremias are common electrolyte disturbances with significant morbidity and mortality. In chronic dysnatremias a slow correction rate (<10 mmol/L/24 h) is indicated to avoid neurological complications. In acute dysnatremias (occurring <48 h) a rapid correction rate may be indicated. Most guidelines do not differ between acute and chronic dysnatremias. In this review, we focus on the evidence-based treatment of acute dysnatremias. METHODS: A literary search in PubMed and Embase. A total of 72 articles containing 79 cases were included, of which 12 cases were excluded due to lack of information. RESULTS: Of 67 patients (70% women) with acute dysnatremia, 60 had hypo- and 7 had hypernatremia. All patients with hyper- and 88% with hyponatremia had a rapid correction rate (> 10 mmol/L/24 h). The median time of correction was 1 day in patients with hypo- and 2.5 days in patients with hypernatremia. The mortality was 7% in patients with hypo- and 29% in patients with hypernatremia. INTERPRETATION: Severe acute dysnatremias have significant mortality and require immediate treatment. A rapid correction rate may be lifesaving and is not associated with neurological complications. Chronic dysnatremias, on the other hand, are often compensated and thus less severe. In these cases a rapid correction rate may lead to severe cerebral complications.

A causality dilemma: ARFID, malnutrition, psychosis, and hypomagnesemia.

We present a novel case of a woman with coincident occurrence of auditory and visual hallucinations, electrolyte disturbances, chloride unresponsive alkalosis, and an eating disorder. The patient was ultimately diagnosed with Gitelman syndrome comorbid with schizophreniform disorder and avoidant restrictive food intake disorder. Eating disorders are often associated with electrolyte abnormalities which, in turn, can cause or contribute to other neuropsychiatric symptoms. At the same time, psychotic disorders can lead to food intake aversions or overconsumption of fluids with associated effects on electrolyte balance. In this case, a third factor, Gitelman syndrome, resulted in persistent hypomagnesemia with metabolic alkalosis and, while separate from her eating disorder, simultaneously reinforced the patient's strong food preferences, excessive fluid intake, and excessive movement related to her complaints of persistent joint pain.

Hyponatremia Presenting with Recurrent Mania.

Primary psychogenic polydipsia (PPD) is a chronic, relapsing condition in which there is a disturbance in thirst control primarily due to an underlying disorder such as a psychogenic condition. It is characterized by an increase of fluid intake along with excretion of excessive amounts of dilute urine exceeding 40 to 50 mL/kg of body weight. PPD is typically seen in patients with schizophrenic symptoms due to elevated levels of dopamine that stimulate the thirst center or in patients with a psychiatric history receiving anticholinergic drugs. There are many reported cases of PPD related to an underlying schizophrenia disorder, but rarely is PPD seen in bipolar patients. We herein report a case of recurrent mania in a patient from a community hospital, who presented with chronic hyponatremia due to PPD. The patient had a history of bipolar disorder type 1 and was admitted to the hospital four times within three weeks with hyponatremia and presenting symptoms of mood lability, psychomotor agitation, pressured speech, racing thoughts, sleeping disturbances, distractibility, and inflated self-esteem. These were the same circumstances and manic presentation in her subsequent medical admissions. Due to her repeat manic presentation and consistently low sodium levels, we believe that her manic symptoms were a result of hyponatremia due to PPD. This patient serves as a unique case wherein switching medications and treating with oral sodium chloride did not prevent the manic episodes as she continues to become hyponatremic secondary to PPD. Due to the difficulty in managing and diagnosing a patient like this, case studies are helpful in studying treatment and maintenance for future cases.

Acetazolamide: Treatment of Psychogenic Polydipsia.

We are reporting a case of psychogenic polydipsia from a State of Ohio psychiatric hospital. The patient has a known five-year history of psychogenic polydipsia with recurrent hyponatremia and has been diagnosed with schizoaffective disorder bipolar type 1, according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria, for the past two decades. There was a marked improvement with the use of acetazolamide, resulting in a decreased compulsion to drink fluid and improvement of his hyponatremia. The patient was observed for six months. We evaluated the water balance of the patient with diurnal weight measurements (DWG) and a weekly comprehensive metabolic panel (CMP) to monitor Na⁺ levels. His symptoms and hyponatremia were improved with acetazolamide. The treatment was well tolerated without any adverse effects and improved his quality of life.

Psychogenic Polydipsia - Management Challenges.

Compulsive water drinking or psychogenic polydipsia is now increasingly seen in psychiatric populations. Effects of increased water intake can lead to hyponatremia causing symptoms of nausea, vomiting, seizures, delirium and can even be life threatening if not recognized and managed early. Here we present a 35-year old adult who was diagnosed with psychogenic polydipsia and was successfully managed with a combination of pharmacotherapy, fluid restriction and psychosocial management.