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 Arieti's third stage of this disorder. A longitudinal study design, rather than our cross-sectional one, would be necessary to assess developmental changes in schizophrenia.

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.

Absence of carbamazepine-induced hyponatremia among patients also given lithium.

Of 33 chronically psychotic patients in a state hospital, 17 received carbamazepine, 13 received carbamazepine and lithium, and three received carbamazepine and then the combination. There was a significant difference in serum sodium level between the patients receiving carbamazepine alone (mean +/- SD = 138.4 +/- 4.3 meq/liter) and those also receiving lithium (141.8 +/- 1.6 meq/liter). (A similar difference was seen for the patients who received the two treatments serially.) Age, sex, diagnosis, age at diagnosis, seizure disorder, antipsychotic drugs, and serum carbamazepine level did not explain this difference. The protection against hyponatremia provided by the carbamazepine-lithium combination occurred despite lithium's tendency to increase polyuria.

Chronic neuroleptic exposure in bipolar outpatients.

BACKGROUND: Although the chronic use of neuroleptic medications is generally discouraged in patients with bipolar disorder, data on the actual extent of this practice are relatively scarce. METHOD: All bipolar patients receiving treatment at the Connecticut Mental Health Center on September 1, 1994, were identified through a computerized administrative database; the medical record was then examined. Patients were included in the study if (1) the last two recorded diagnoses in the chart were concordant for bipolar disorder and (2) the patient had not been hospitalized in the past year. RESULTS: Of 49 patients meeting review criteria, 33 (67%) met criteria for chronic neuroleptic exposure. The mean +/- SD continuous neuroleptic dosage for these 33 outpatients was 416 +/- 527 mg/day chlorpromazine (CPZ) equivalents. The dosage distribution was skewed, with 17 (52%) receiving < or = 200 mg/day CPZ [corrected] equivalents. CONCLUSION: Chronic neuroleptic administration occurred frequently in our sample of nonhospitalized bipolar outpatients.

Diurnal variation in water homeostasis among schizophrenic patients subject to water intoxication.

Among seven schizophrenic patients subject to water intoxication (six men and one woman, mean age 39.1 +/- 6.9 years), we measured serum sodium, plasma arginine vasopressin, and urine osmolality at 7 a.m. and 4 p.m. on eight consecutive Thursdays. On the days of greatest diurnal change in serum sodium, the 7 a.m. serum sodium was 141.1 +/- 1.8 mEq/l and the 4 p.m. value was 129.9 +/- 3.2 mEq/l. Plasma vasopressin also tended to be lower at 4 p.m. but, in many cases, was inadequately suppressed for the level of hyponatremia. The urine was dilute at both 7 a.m. and 4 p.m. and mean urine osmolality did not differ at the two times. In three patients, urine osmolality was consistently subnormal relative to plasma vasopressin at both 7 a.m. and 4 p.m. This abnormality was consistent with nephrogenic diabetes insipidus secondary to lithium and, possibly, phenytoin which the patients received to protect them against hyponatremia. We conclude that the combination of polydipsia and abnormal osmoregulation of vasopressin secretion contributes importantly to the afternoon hyponatremia found in schizophrenic patients subject to water intoxication.

Abnormal diurnal weight gain among long-term patients with schizophrenic disorders.

We found diurnal weight gain to be abnormal among 65 long-term patients with schizophrenic disorders. Patients were weighed at 7 a.m. and 4 p.m. serially and diurnal weight gain was normalized (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 2.2 +/- 1.5% for 47 male patients compared (P = 0.001) with 0.6 +/- 0.4% for 11 male controls. NDWG was 1.7 +/- 0.7% for 18 female patients compared (P less than 0.0001) with 0.5 +/- 0.3% for 14 female controls. We hypothesize that NDWG may be an index of both the severity and duration of the schizophrenic disorder.

Similarity of patterns of urine excretion among nonpolyuric and polyuric patients with thought disorders.

From a study population of 29 institutionalized chronically psychotic patients, 70% of whom had schizophrenic or schizoaffective disorders, nonpolyuric and polyuric patients had similar diurnal patterns of urine excretion. Patients excreted a larger portion of daily urine volume after noon (55%) than before noon (45%).

Diurnal weight gain in chronic psychosis.

We found diurnal weight gain to be abnormal among 93 chronically psychotic patients, most of whom had schizophrenia. They were weighed at 7 a.m. and 4 p.m. weekly for 3 weeks. 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 dividing the result by the 7 a.m. weight. NDWG was 1.7 +/- 1.0 percent for the study sample, 0.6 +/- 0.4 percent for 16 acutely psychotic controls, and 0.5 +/- 0.4 percent for 29 normals. More than 60 percent of the study sample had abnormal NDWG values. NDWG related to antipsychotic drug dose (r = 0.290, p = 0.005) with variability in drug dose accounting for 8 percent of the variability in NDWG. This report provides yet another piece of evidence that disordered water balance is common in chronic psychiatric patients. The etiology is unknown, but it may relate to subtle brain abnormalities in the regulation of fluid intake and excretion.

Failure of antipsychotic drug dose to explain abnormal diurnal weight gain among 129 chronically psychotic inpatients.

1. The diurnal weight gain was found to be abnormal among 129 chronically psychotic inpatients. 2. The patients were weighed at 7 a.m. and 4 p.m. weekly for three weeks. 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. 3. NDWG was 2.2 +/- 1.5 percent for 87 male patients compared (p less than .0001) with .53 +/- .41 for 14 male controls. 4. NDWG was 1.8 +/- 1.0 percent for 42 female patients compared (p less than .0001) with .49 +/- .30 for 15 female controls. 5. Seventy percent of male and female patients had NDWG values greater than two standard deviations above the mean values of controls. 6. Differences in age, sex, morning weight, antipsychotic drugs, lithium, carbamazepine, phenytoin, blood pressure, and pulse did not explain these findings.

Therapeutic approaches for survivors of disaster.

Common psychiatric responses to disasters include depression, PTSD, generalized anxiety disorder, substance-abuse disorder, and somatization disorder. These symptom complexes may arise because of the various types of trauma experienced, including terror or horror, bereavement, and disruption of lifestyle. Because different types of disaster produce different patterns of trauma, clinical response should address the special characteristics of those affected. Traumatized individuals are typically resistant to seeking treatment, so treatment must be taken to the survivors, at locations within their communities. Most helpful is to train and support mental health workers from the affected communities. Interventions in groups have been found to be effective to promote catharsis, support, and a sense of identification with the group. Special groups to be considered include children, injured victims, people with pre-existing psychiatric histories, and relief workers.

Diurnal weight gain as a predictor of serum sodium concentration in patients with psychosis, intermittent hyponatremia, and polydipsia (PIP syndrome).

Ten male patients (mean age 37.3 +/- 6.4 years) with psychosis, intermittent hyponatremia, and polydipsia (PIP syndrome) underwent measurement of weight, sitting and standing blood pressure, and serum sodium concentration at 7 a.m. and 4 p.m. weekly for 8 consecutive weeks. Blood pressure was higher in the afternoon than in the morning. The diurnal decrease in serum sodium (141.4 +/- 2.8 to 134.2 +/- 4.8 mEq/l) was associated with a diurnal increase in weight (78.4 +/- 9.7 to 80.0 +/- 10.3 kg). When the weight increase was normalized by dividing by 7 a.m. weight (NDWG), the following relationship evolved: diurnal serum sodium decrease = 3.060 + [201.728 x NDWG]. Therefore, NDWG accounted for 63.1% of the variability of serum sodium. Using the known relationship of plasma water, total body water, and total body weight, we calculated that antidiuresis (afternoon weight gain) accounted for 62.5% of afternoon hyponatremia. Thus, two separate methods of calculating the relationship between antidiuresis and hyponatremia provided remarkably similar findings. We derived a table to predict 4 p.m. serum sodium values based on 7 a.m. weight, 7 a.m. serum sodium, and 4 p.m. weight.

Diurnal weight gain among patients with mental retardation.

We compared the diurnal weight gain of 46 patients with mental retardation to that of 21 patients with organic mental syndromes. They were weighed at 7 a.m. and 4 p.m. weekly for 3 weeks. We normalized the diurnal weight gain as a percentage by subtracting the 7 a.m. weight from the 4 p.m. weight, multiplying the difference by 100, and dividing the result by the 7 a.m. weight. Normalized diurnal weight gain was abnormal among one fourth of patients with mental retardation and two thirds of those with organic mental syndromes. Differences in age, sex, baseline weight, antipsychotic drugs, lithium, carbamazepine, blood pressure, and pulse did not explain our results. We believe that our findings provide additional evidence to separate patients with mental retardation from those with psychosis.

Tornado disasters and stress responses.

Each year, a number of tornados rip through Kentucky, leaving fear, destruction, and human injury in their path. Persons who endure these catastrophes often experience a variety of stress responses. The psychological and medical sequelae include depression, acute and post-traumatic stress disorders, substance abuse, anxiety, and somatization. It is especially important for the Kentucky practitioner to be able to recognize and screen for pathology following a tornado disaster in order to provide leadership in ascertaining treatment for such stress responses.

Psychological response to disaster: implications for Hawaii.

Given the frequency of natural disasters in Hawaii, it is important for practitioners to be aware of the numerous resulting psychological responses and risk factors, especially those unique to Hawaii. Practical guidelines are presented for practitioners, both in providing leadership during the disaster and in screening for psychopathology thereafter.