MRI changes during water loading in patients with polydipsia and intermittent hyponatremia.

OBJECTIVE: Patients with polydipsia and intermittent hyponatremia have greater ventricle-brain ratios (VBRs) than matched patients without polydipsia and intermittent hyponatremia and normal subjects. Unlike previous studies, this study controlled for the impact of water loading when examining the volume of intracranial structures. METHOD: Under controlled conditions, eight male schizophrenic patients with polydipsia and intermittent hyponatremia were first assigned to either normal fluid intake or oral water loading and then the alternative condition the following day. Magnetic resonance imaging (MRI) volumetric measurements were made with the use of a standardized protocol. RESULTS: During water loading, total VBR and lateral ventricle volume significantly decreased by 13.1% and 12.6%, respectively. A strong association between change in serum sodium concentration and change in VBR was noted across conditions. CONCLUSIONS: These findings indicate that 1) water loading does not account for the diminished brain volume observed in patients with polydipsia and intermittent hyponatremia in previous studies, and 2) hyponatremia can significantly alter brain morphology on MRI.

Differential effects of neuroleptic and clozapine on polydipsia and intermittent hyponatremia.

Recent reports indicate that clozapine may dramatically decrease both polydipsia and intermittent hyponatremia associated with chronic psychosis. In contrast, there are conflicting reports regarding the impact of standard neuroleptic treatment in this syndrome. We review the relevant literature examining the effects of antipsychotics on the excessive thirst drive and inordinate arginine vasopressin activity observed in patients with water intoxication. Confounding interpretation of the current literature are inconsistent use of diagnostic criteria and treatment outcome measures. If results of preliminary trials is substantiated, clozapine treatment may provide an opportunity to correct methodological problems and provide greater insight into the syndrome of polydipsia and intermittent hyponatremia.

Clozapine treatment in polydipsia and intermittent hyponatremia.

BACKGROUND: Recent case reports indicate that clozapine treatment diminishes excessive diurnal weight gain and alleviates hyponatremia observed in some chronically psychotic patients. We examined the influence of clozapine on sodium metabolism and water regulation across a group of patients with the syndrome of polydipsia and intermittent hyponatremia. METHOD: Eleven patients with treatment-resistant DSM-III-R schizophrenia or schizoaffective disorder were studied. Each had a history of repeated diurnal weight gains of greater than 10% with at least one documented bout of hyponatremia in the 6 months before clozapine treatment. We utilized a target weight protocol and serial laboratory measures to compare changes in sodium metabolism and water regulation during 26 weeks of standard antipsychotic medication and 26 weeks of clozapine treatment. RESULTS: Across patients, we found significant improvement in routinely monitored 6 a.m. and 4 p.m. serum sodium, reflecting normalization of sodium metabolism. We also found that the frequency (as reflected by diurnal weight gain), severity (lowest serum sodium), and estimated quantity (calculated urine volume) of polydipsia improved across patients. Improvement in polydipsia and hyponatremia was associated with decreased necessity for monitoring and restrictive interventions, and tended to be associated with psychiatric improvement. CONCLUSION: We found a corrective and stabilizing effect of clozapine on polydipsia and intermittent hyponatremia. Future studies need to examine the relationship of psychiatric improvement and alterations in the regulation of sodium and water physiology to our findings.

Cigarette use, drinking and voiding in schizophrenic patients with polydipsia and hyponatremia.

Pre-smoking versus post-smoking amounts of drinking and voiding were compared in ten state hospital patients with schizophrenia and polydipsia. Cigarette use was significantly correlated with total amount drunk but was not associated with increased drinking or decreased voiding immediately following smoking. These findings revealed no nicotine effects upon thirst drive or urinary output, but suggest that drinking and smoking represent associated repetitive behaviors.

Affect processing in chronically psychotic patients: development of a reliable assessment tool.

We developed an economical clinical tool for assessing affect processing deficits in patients with chronic schizophrenia and schizoaffective disorder. Using trained raters, we assessed spontaneous prosody, prosodic comprehension, prosodic repetition, and recognition of facial affect. High interrater reliability and good separation between subscales was demonstrated. Our tool discriminated between the performance of subjects versus controls on measures of spontaneous prosody and prosodic comprehension, suggesting the presence of prosodic deficits in psychiatric patients. These findings underscore the need for reliable and valid testing tools which will allow greater understanding of affective prosodic processing deficits in psychiatric populations.

Neuropsychological manifestations of hyponatremia in chronic schizophrenic patients with the syndrome of psychosis, intermittent hyponatremia and polydipsia (PIP).

We examined the neuropsychological sequelae of water intoxication in nine schizophrenic patients with the syndrome of psychosis, intermittent hyponatremia and polydipsia (PIP). Patients were assessed using a standardized test battery on two occasions following laboratory blood work: once during hyponatremia (serum sodium < 130 mmol/l) and once during normonatremia (serum sodium > 136 mmol/l). Results revealed significant deficits during hyponatremia involving complex information processing skills such as mental flexibility and verbal fluency. In contrast, short-term memory was intact and no deficits in sustained attention or visual-motor scanning were observed. Our results underscore the dramatic fluctuations in neuropsychological functioning due to metabolic and osmotic changes during water loading in PIP syndrome patients. In addition, we found that the neuropsychological effects of hyponatremia are remarkably consistent across patients. These complications, if not recognized, are likely to contribute to worsening of psychosis despite appropriate pharmacological treatment while severely limiting patient ability to actively participate in behavioral interventions.

Multidisciplinary approach to psychosis, intermittent hyponatremia, and polydipsia.

The syndrome of psychosis, intermittent hyponatremia, and polydipsia (PIP syndrome), seen in the seriously mentally ill, can result in severe biopsychosocial impairment, including an excessive death rate if not identified early. Because of its impact on the health, functioning, and quality of life of the seriously mentally ill patient, all mental health care providers must be aware of the signs and symptoms of PIP syndrome. Physiological, psychological, behavioral, self-care, and social factors all play a role in the manifestation of the syndrome; it follows that a multidisciplinary approach is crucial to ensure early detection, monitoring, and treatment of this problem both in the hospital and in the community. This article explains how we have incorporated the strengths of various disciplinary strategies into a unified treatment model for managing PIP syndrome and its sequelae.

Behavioral analysis of drinking behaviors in polydipsic patients with chronic schizophrenia.

The authors describe drinking and voiding behaviors that differentiate between psychiatric patients with polydipsia and patient controls. Observations of 9 polydipsic patients and 6 controls were conducted for 153 hr and had high interrater reliability. Polydipsic patients drank 3 times as frequently, ingesting 5 times as much fluid as the controls. They voided 4 times as often, eliminated 5 times as much urine, and evidenced greater diurnal weight shifts. A higher bout frequency and a shorter time interval between drinks differentiated polydipsic patients from controls, whereas amount drunk per bout and rate of drinking were similar across groups. The authors' findings have implications for improving detection of polydipsia, understanding its neurobiology, and developing more efficacious behavioral interventions.

Dysphoria: a major symptom factor in persons with disability or chronic illness.

Depression frequently is diagnosed in persons with chronic illness or following the onset of disability. The overlap of symptoms of many chronic illnesses and disabling conditions with depression may lead to an overestimation of depression in such populations. Some investigators have proposed revised criteria for diagnosing depression in these conditions without an understanding of the contribution of diagnostic criteria in disabling conditions. This study investigated the nature of depressive symptom criteria constellations by individually factor analyzing the Inventory to Diagnose Depression (based on DSM-III diagnostic criteria) in spinal cord injury (n = 134), rheumatoid arthritis (n = 78), student (n = 140), and community (n = 150) groups. A four-factor solution emerged, with the first factor labeled "dysphoria" being represented by symptoms of negative self-evaluations, depressed affect, and suicidal ideation. The results indicate that a core element of the syndrome of depression is dysphoria, which suggests that the contribution of somatic items may be less important to the identification of the depressive syndrome in chronic illness.

The development of a Somatic Amplification Rating Scale for low-back pain.

The development of a new scale, the Somatic Amplification Rating Scale (SARS), for the quantification of exaggerated (nonorganic) motor, sensory, and pain responses occurring during a standardized physical examination is described. This 13-item scale, partially based on a measure of nonorganic physical signs developed by Waddell et al, was administered to 127 low-back pain patients at an outpatient pain center. It was determined that the 13-item scale could be shortened to seven items with improved ease of administration and little loss of reliability and validity. Interrater reliability of the finalized seven-item scale was excellent (R = 0.93). Finally, it was determined that patients with high SARS scores were significantly more likely to be receiving workers' compensation benefits and to endorse physical symptoms with greater intensity on psychologic testing (Symptom Checklist 90).

Association between stereotypic behavior and polydipsia in chronic schizophrenic patients.

We assessed temporal associations between polydipsia and motor stereotypies in chronic schizophrenia. Subjects included: (a) a polydipsic patient with marked stereotypies; (b) a polydipsic patient with no history of stereotypy; (c) a nonpolydipsic patient. Stereotyped grooming and pacing were significantly associated with drinking for polydipsic patients only (polydipsic patients evidenced a 87% and 66% concordance between excessive grooming and drinking versus 12% in the control). Our findings provide the first empirical demonstration that polydipsia is temporally associated with other repetitive behaviors. The use of behavioral assessment to examine etiological theories suggesting that polydipsia stems from interacting environmental, biological, and pharmacological variables is discussed.

Development and validation of a behavioral observation measure for the syndrome of psychosis, intermittent hyponatremia, and polydipsia.

A behavioral observation scale (Virginia Polydipsia Scale; VPS) for monitoring drinking patterns was developed and its reliability tested during 25 hours of tandem ratings among six patients with the syndrome of psychosis, intermittent hyponatremia, and polydipsia (PIPS). These ratings were compared to those collected from a control group of six psychiatric inpatients who were similarly observed for 25 hours. The scale was subsequently used to assess day-long drinking in a single PIPS patient. Results demonstrated that the VPS can be reliably administered by trained raters and that it clearly differentiates the drinking patterns of PIPS patients from controls. In addition, our findings highlight associations among drinking behaviors, psychiatric functioning and low serum sodium concentration. On balance, these results support using observational measures of drinking behaviors in future studies of PIPS patients.

Case report: recurrent pseudocyesis in a male patient with psychosis, intermittent hyponatremia, and polydipsia.

This report describes a case of recurrent pseudocyesis in a man with psychosis, intermittent hyponatremia, and polydipsia. The pseudocyesis was documented on three separate occasions coinciding with bouts of acute hyponatremia and rapid weight gain stemming from ingestion of large amounts of water. In contrast, no pseudocyesis was elicited during intervening normonatremic states. Abdominal distention, neuropsychological deterioration, and worsening of psychosis during acute hyponatremia are considered as contributing factors to the pseudocyesis.

Direct assessment of beliefs and attitudes of chronic pain patients.

Traditional approaches to psychological assessment of chronic pain patients have centered either on underlying psychopathology or environmental reinforcers for pain behavior. The current research focuses on patient beliefs and attitudes about their pain and its treatment, an additional dimension which appears to be important in treatment outcome but has seldom been systematically examined. Patients' ratings of agreement/disagreement with information presented in a brief educational videotape about chronic pain were examined via factor analysis. The four factors which emerged from the rating were: admission of emotionality, perceived relevance of the videotaped information, acknowledgment of personal responsibility in the treatment, and discrimination of noninvasive treatments. These four factors appear to have convergent validity with those suggested by other researchers. The validity and utility of this approach to patient assessment in rehabilitation settings are discussed.

Chronic pain patients' beliefs about their pain and treatment outcomes.

A novel assessment procedure measuring chronic pain patients' agreement with information presented on a clinic orientation videotape was evaluated as a predictor of short-term treatment outcome. One hundred randomly selected outpatients viewed a 15-minute videotape detailing conservative approaches to pain management and completed a questionnaire measuring factual recall of the videotape presentation and their acceptance or rejection (ie, agreement) of this information. Patient ratings of satisfaction with treatment were assessed one month after treatment. Multivariate analyses revealed that extent of agreement with the videotape content was significantly associated with lower pain ratings, increased ratings of physical ability, and higher treatment satisfaction. Prognostic use of this procedure for identifying patients at risk for nonadherence to treatment is discussed.

Behavioral treatment of dizziness secondary to benign positional vertigo following head trauma.

Benign positional vertigo (BPV) represents a challenge to rehabilitation due to the subjective nature of the complaint of dizziness, frequent failure of pharmacologic intervention, and complicating psychologic factors. Behavioral therapy was used to treat a 26-year-old woman who complained of debilitating dizzy spells after mild head injury sustained in a motor vehicle accident. During a three-week baseline period before treatment, the patient reported a weekly average of 48 dizzy spells, which prevented participation in independent activities and kept her homebound and psychologically distressed. Nine-week behavioral treatment included biofeedback-assisted relaxation training, psychologic counseling, gaze-fixation practice, desensitization exercise, and generalization training. This protocol has been used successfully to train aviators to combat vertigo and nausea in flight. Our regimen included hourly recording of physical activity, notation of frequency of dizzy spells, and use of behavioral methods during nine weeks. The patient reported 90% reduction in dizzy spells and full resumption of independent activities including driving and athletics. Results are discussed in the context of behavioral problems associated with BPV and application of behavioral methods to the complaint of dizziness.