Polydipsia in the chronically mentally ill: a review

Development of diagnostic criteria and severity scale for polydipsia: A systematic literature review and well-experienced clinicians' consensus

Despite the clinical importance of polydipsia, no diagnostic criteria or severity scales that comprehensively assess this condition are available. Thus, we aimed to develop diagnostic criteria and a severity scale for polydipsia based on a systematic review and well-experienced clinicians' consensus. We performed a systematic review, identified 27 studies related to diagnostic criteria or severity classification for polydipsia, and extracted items used to assess polydipsia in these studies. Ten well-experienced clinicians-5 psychiatrists and 5 nurses-participated in the Delphi method. They evaluated 39 items extracted based on the results of the systematic review regarding (1) their necessity in diagnosing and assessing the severity of polydipsia, and (2) their relative importance rated on 7-point scale among the items included in the severity scale. The Polydipsia Diagnostic Criteria (PDC) included 4 essential items-excessive drinking, low serum sodium level or low serum osmolality, abnormal normalized diurnal weight gain, and low urine specific gravity-based on consensus reached using the Delphi method. The Polydipsia Severity Scale (PSS) included 13 items with a maximum score of 59. The first diagnostic criteria and symptom scale for polydipsia were developed based on the findings of a systematic review and well-experienced clinicians' consensus.

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.

Psychogenic polydipsia: the result, or cause of, deteriorating psychotic symptoms? A case report of the consequences of water intoxication

Water intoxication is a rare condition characterised by overconsumption of water. It can occur in athletes engaging in endurance sports, users of MDMA (ecstasy), and patients receiving total parenteral nutrition. This case outlines water intoxication in a patient with psychogenic polydipsia. When the kidney's capacity to compensate for exaggerated water intake is exceeded, hypotonic hyperhydration results. Consequences can involve headaches, behavioural changes, muscular weakness, twitching, vomiting, confusion, irritability, drowsiness, and seizures. Cerebral oedema can lead to brain damage and eventual death. In this case, psychogenic polydipsia led to significant hyponatraemia, cerebral oedema, and tonic-clonic seizures. Differential diagnoses for hyponatraemia are outlined. The aetiology of psychogenic polydipsia is uncertain, but postulated hypotheses are explored. Psychogenic polydipsia occurs in up 20% of psychiatric patients and this case serves to remind us to be cognizant of water overconsumption.

Acute correction of hyponatremia secondary to psychogenic polydipsia

Background:

Psychogenic polydipsia is prevalent amongst psychiatric patients, but less common in the general population. Generally, hyponatremia ensues with complications of cerebral edema resulting in confusion, seizures, coma, and death. Rapid correction of serum sodium levels can lead to further complications of osmotic demyelination of neurons, e.g. central pontine myelinolysis.

Case Report:

We present a case of a 32-year-old male who presented with seizures while being treated at a drug rehabilitation facility. He was discovered to be hyponatremic secondary to suspected psychogenic polydipsia. The patient impressively responded to treatment of fluid restriction and desmopressin and symptoms improved.

Conclusions:

Among the causes of hyponatremia, psychogenic polydipsia may be more difficult to diagnose especially if an apparent psychiatric condition is not present. Current literature supports cautious correction of hyponatremia to prevent complications. However, rapid corrections may be driven by the physiology of the patient and may not be avoidable. Fortunately, our case illustrates rapid, positive outcomes for the patient.

Polydipsia screening tool

Polydipsia is a condition whereby individuals consume excessive amounts of liquids, which is common in patients with schizophrenia. A 17-item Polydipsia Screening Tool (PST; Copyright 2000 by Sheila Reynolds) was evaluated for psychometric properties. Five nurses and 70 psychiatric residents in a 92-bed nursing home comprised the samples. The interrater reliability (mean intraclass correlation coefficient) was 0.84. The average test-retest agreement was 92.4% with agreement ranging from 75% to 100%. Internal consistency of the tool was 0.79. Sensitivity and specificity were 80% and 68%, respectively. Additionally, validity of the PST was supported using a medical record history of polydipsia, low serum sodium, and low specific gravity.

Patient perceptions of self-induced water intoxication

This study comprehensively examines self-induced water intoxication (SIWI) from a patient perspective including demographics, reasons for seeking fluids, patterns/behaviors of fluid seeking, and symptoms frequently experienced while in a state of SIWI. The subjects were 45 of an original convenience sample of 62 individuals with a serious mental illness (SMI), hospitalized in a long-term state psychiatric facility, who engaged in self-induced water intoxication. All participants were interviewed in a structured format to complete a 40-item Likert-type questionnaire developed for the study, titled the Self-induced Water Intoxication Questionnaire (SIWIQ). In the study, the majority of participants were smokers, and reported no past problem with alcohol. SIWI occurred more in males than females, and was more predominant in those participants who had longer hospital stays. Anger and vomiting were found to be the two most predominant symptoms experienced when excess fluid consumption occurred. Behaviors of drinking from the shower, the toilet, and one's own urine are consistent with findings of previous studies and illustrate the difficulty in keeping individuals with SIWI from fluids. Data show that participants with SIWI experience considerable anxiety and cognitive difficulties and express these as reasons for engaging in excess fluid consumption. Boredom, obtaining a high, and sad mood were also predominant reasons identified for excess fluid drinking. Significant relationships were found and discussed. The findings provide support for the position that SIWI represents an attempt at treatment by the dysfunctional individual and is pursued for anxiolytic effects and alleviation of boredom. The data support the idea of approaching the problem from a dysfunctional coping framework, realizing that SIWI is a very complex problem, needing examination and intervention at multiple levels, beyond exclusive focus on fluid control.

EGb 761 inhibits stress-induced polydipsia in rats

The effect of daily treatments with Ginkgo biloba extract (EGb 761, IPSEN, France) on body weight and water intake of rats was followed for 15 days. During this period, two groups of rats, under slight ether anesthesia, were intubated and fed either EGb 761 (100 mg/kg b.wt. in 5% ethanol) or, for sham controls, 5% ethanol alone (6.6 ml/kg b.wt.). The increase in body weight was similar for the control and experimental groups. However, during the same period of time, the water intake, ml water/g b.wt./24 h, increased 37% in the controls. In EGb 761-treated rats, water intake remained unchanged. This suggests that EGb 761 treatment inhibits the development of polydipsia due to the stress of daily handling and intubation.

The individual who is severely and persistently mentally ill: directions for research and practice

Psychiatric mental health nursing has not invested time and resources in the care of those with severe and persistent mental illness. In this article, current nursing research is reviewed and practice/research directions are delineated in the following areas: acute and chronic manifestations of symptoms, behavioral manifestations related to institutionalization, responses to psychiatric disorders over time, the long-term effects of psychotropic medication on behavior, and the impact of physical illnesses on psychiatric disorders. Knowledge is sorely needed in all of these areas to improve the nursing care of those persons with severe and persistent mental illness.

Nursing program to meet the challenge of caring for patients with water intoxication

This article describes a program that is effective in working with psychiatric patients who have trouble with excessive water intake. The purpose of the program is to provide consistent treatment in a controlled and therapeutic environment in which the special needs of these patients can be met. We incorporate a variety of nursing interventions suggested by the literature to help meet the goals of the program. As a result of the program, disruptive behavior has decreased and patients have learned skills to help them manage their illness. An additional benefit of the program is that working with water intoxication patients is no longer stressful for staff.

Target WEIGHT Procedure: PREVENTING WATER INTOXICATION

1. Prevention of water intoxication depends on early intervention for polydipsic patients who seem to be retaining fluid. The Target Weight Procedure is designed to detect early signs of fluid retention by means of weight gain and low sodium levels. 2. The use of this protocol, in addition to successfully decreasing the number of acute water intoxication episodes, has also led to increased awareness of the meaning of patient behavior, an increased sense of control of patients with water intoxication over their behavior, and an increased feeling of competence among the staff. 3. The success of the protocol seems to be based on its purpose of identifying patients at risk and those with an impending episode, as well as secondary advantages, for example, giving the patients the option to alter their behavior to be removed from the protocol.

When They Drink Too Much Nursing Interventions for Patients with DISORDERED WATER BALANCE

Disordered water balance affects as many as 60% of severely psychiatrically disabled persons. Most patients do not progress to the point of a medical emergency, but are in a state of mild chronic intoxication, making them unavailable for treatment and requiring nursing care to treat the effects of the chronic intoxicated state. Interventions depend on the severity of the disordered water balance and vary from teaching fluid intake control to controlling all patient access to fluids. Nursing management of water intoxication is a trial and error approach. Through a thorough assessment and close observation of the patient, the nurse can determine which interventions would be most appropriate for the patient.