Seasonal stability of water balance among schizophrenic patients subject to water intoxication

1. Diurnal weight gain, afternoon hyponatremia, and polyuria were assessed for one year among eight male schizophrenics subject to water intoxication. 2. The authors 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 ranged between 2.69 +/- .99 and 3.34 +/- 1.32 percent (F [3, 5] = .885, p = .509) during the four seasons of the year. 4. The seasonal decrease in afternoon serum sodium compared to its morning counterpart ranged between 4.23 +/- 1.96 and 6.14 +/- 2.82 mmol/l (F [3, 5] = 2.212, p = .205). 5. Seasonal polyuria ranged between 8.2 +/- 3.5 and 8.8 +/- 3.2 liters (F [3, 5] = .228, p = .873). 6. Among schizophrenics subject to water intoxication, the seasonal stability in our three parameters of water imbalance suggest they may be used to follow patients with altered water homeostasis over time. This finding has both clinical and research implications.     

Self-induced water intoxication in schizophrenic patients

This case report concerns two schizophrenic patients with "psychogenic" polydipsia, without any underlying somatic disease. Although case A showed a correlation between excessive water intake and severity of psychomotor disturbance, this could not be safely diagnosed as a water intoxication because the sodium serum level was normal. The lowered sodium serum level in case B, however, allowed us to conclude that the manifestation of grand mal was a sign of a genuine water intoxication. 27 casuistic studies on 67 patients with the syndrome of self-induced water intoxication in schizophrenics are then reviewed. Finally, a variety of diagnostic and pathogenetic problems of this syndrome is discussed, with special reference to the role of inadequate ADH secretion.     

Death from self-induced water intoxication among patients with schizophrenic disorders

Review of 60 consecutive records of patients who died before the age of 53 years in a state mental hospital revealed that 27 of those patients (45%) had a schizophrenic disorder. Of those 27 patients, five (18.5%) died of the complications of self-induced water intoxication and schizophrenic disorders (SIWIS). Clinical, laboratory, and autopsy features of those five SIWIS patients and of an additional five SIWIS cases obtained from the literature include psychosis, polydipsia, polyuria, severe hyposthenuria (specific gravity 1.003 or less), hyponatremia, seizures, coma, and cerebral and visceral edema. SIWIS characteristically develops during Arieti's third or "preterminal" stage (5 to 15 years after onset of psychosis) of schizophrenic disorders and it must be included in the differential diagnosis of unexplained death among psychiatric patients. As there are no pathognomonic SIWIS tissue changes, the pathologist must carefully integrate clinical, laboratory, and autopsy findings to arrive at the proper diagnosis. When premortem findings of polydipsia and hyponatremia are not available, evidence of antecedent severe hyposthenuria and postmortem vitreous humor hyponatremia of less than 120 mEq/1 are strongly supportive of the diagnosis of death due to SIWIS.     

Fatal self-induced water intoxication among schizophrenic inpatients.

Between 1986 and 1998, a review of 61 records of patients who died before the age of 53 years in eight psychiatric departments whose catchment area had a total population of 559,429 inhabitants revealed that 24 (39.3%) of those patients had a schizophrenic disorder. Of those 24 patients, one (4.17%; 95% CI: 0-21%) died from complications of self-induced water intoxication (SIWIS). Among the 37 remaining patients, two (5.4%; 95% CI: 0-18%) died from complications of SIWIS.     

Oral sodium chloride in the management of schizophrenic patients with self-induced water intoxication

Hyponatremia is always present in patients with water intoxication and accounts for many of the life-threatening symptoms and signs found in this population. In schizophrenic patients, water restriction, a cornerstone in the treatment of water intoxication, may be impossible to implement over the course of long-term management. The use of oral sodium chloride administration in such patients and its short-term efficacy in preventing major motor seizures are described.     

Manners of arginine vasopressin secretion in schizophrenic patients--with reference to the mechanism of water intoxication

Water intoxication occurs almost exclusively in many patients with chronic psychiatric disorder. To elucidate the mechanism of this syndrome, we undertook the following animal experiments and clinical study. Twelve rabbits were given neuroleptics for eight weeks. From measurement of arginine vasopressin (AVP) secretion response to osmotic stimuli (fluid deprivation, partaking ad lib. and water loading), we found that chronic neuroleptic administration might raise the sensitivity of AVP escretion response. Then we investigated the manners of AVP secretion during ad lib. drinking in seventeen schizophrenic patients with hyponatremia and sixteen schizophrenic patients without hyponatremia. Normal range of plasma AVP was obtained from healthy volunteers by water loading. Only in both schizophrenic groups was plasma AVP detected below 270 mOsm/kg osmolality. We observed that sensitivity of AVP secretion response to osmolality was decreased in schizophrenic patients, regardless of the presence of hyponatremia. We hypothesize that the primary low sensitivity of AVP secretion response to osmo-receptor and the secondary renal hypersensitivity of AVP receptor may play the major role in the occurrence of water intoxication, linked to SIADH, in schizophrenic patients.     

Individual differences in serum sodium levels in schizophrenic men with self-induced water intoxication

Eight men with chronic schizophrenia and self-induced water intoxication showed marked individual differences in their serum sodium levels. The severity of the intoxication symptoms reflected the amount and speed of change in sodium levels rather than the absolute sodium values.     

Cocaine abuse among schizophrenic patients

Initial studies have indicated that stimulant abuse is prevalent among schizophrenic persons. To assess the phenomenon of cocaine abuse by patients with schizophrenia, 17 male cocaine-abusing schizophrenic patients were compared with 22 male schizophrenic patients who did not use cocaine. The cocaine-abusing subjects had been hospitalized more frequently, were more likely to be of the paranoid subtype, and were more likely to be depressed at the time of interview. It appears that cocaine abuse may influence both the psychopathologic presentation of schizophrenic patients and the intensity of care that they require.     

Naloxone attenuates drinking behavior in a schizophrenic patient displaying self-induced water intoxication.

This study was performed to examine the effect of naloxone on drinking behavior in a schizophrenic inpatient with psychosis, intermittent hyponatremia, and polydipsia (PIP syndrome). His body weight was checked five times daily, and the maximum and minimum weight gains during a day were chosen as an index of polydipsia. Both daily (0.6 mg) and repeated (0.6 mg for 6 days) injections of naloxone suppressed his weight gain significantly for 2 weeks. Withdrawal of the drug for 4 weeks resulted in weight gain recovering to control level. Thereafter, a second trial was performed to examine the long-term effect of this treatment. A daily naloxone (0.6 mg) injection series was performed once every 2 weeks for six series (12 weeks). This drug regimen also suppressed his weight gain in a continuous fashion. The study showed that naloxone seems to be a potential treatment for PIP syndrome and that endogenous opioid systems play a part in the compulsive drinking behavior of the PIP syndrome.     

Patterns of urinary excretion among patients with self-induced water intoxication and psychosis

Parameters of water metabolism were measured serially in nine patients with the syndrome of self-induced water intoxication and psychosis (SIWIP). Clinical and laboratory findings indicated that SIWIP patients are type A of the syndrome of inappropriate antidiuresis. Estimated 24-hour urinary excretion of creatinine and early morning urinary creatinine concentration measurements were used to calculate 24-hour urine volumes. Polyuria was considered present for male patients when excretion was estimated to be greater than 2,600 ml of urine/24 hours or early morning urinary specific gravity was less than or equal to 1.003. Male patients with a specific gravity of less than or equal to 1.003 predictably excreted 28,000 ml of urine/day. Severe hyposthenuria may be a biological marker for a population at risk to develop complications of SIWIP, including seizures, coma, and death.     

Diurnal variation of total plasma tryptophan in depressive patients

Total plasma tryptophan was analysed during a 24-h period in 27 control persons and 42 patients with a diagnosis of endogenous depression. Total plasma tryptophan was unchanged in endogenously depressed patients compared with controls. The effect of one night's sleep reversal was investigated in control persons. During the following day, when the persons were asleep, plasma tryptophan concentration fell below control values. The normal diurnal variation with low values in the night and high values in the daytime disappeared when the persons were kept fasting.     

Water intoxication and syndrome of inappropriate secretion of antidiuretic hormone in schizophrenic patients evaluated by water deprivation and load tests

A study was conducted on 16 schizophrenic patients with compulsive water drinking (CWD) and 10 normal controls, and the relation between serum antidiuretic hormone (ADH) and serum osmolality measured under ordinary conditions of free water intake. A water deprivation test and a water load test were also carried out on 10 schizophrenics with CWD and 10 normal controls. A comparison between the patients and controls showed the following results: the patients showed a significantly high level of serum ADH for their serum osmolality level, and 3 of them were consistent with the syndrome of inappropriate secretion of ADH (SIADH); the urine osmolality after the water deprivation in the patients was relatively low for their serum ADH; inhibition of ADH secretion after the water load was insufficient in the patients; and the water load test proved favorable to water diuresis (106%) in the patients with CWD of less than a 5-year duration, and insufficient diuresis (62.6%) in the patients with CWD of more than a 5-year duration. Two cases of the latter group had SIADH. The dilution and concentration of the urine after the water load were delayed also in the schizophrenic patients without SIADH. These findings suggest a strong possibility that the regulatory mechanism of ADH secretion might be impaired in the schizophrenic patients with CWD.     

Contingent negative variation and attention in schizophrenic and depressed patients

Contingent negative variation (CNV) is supposed to be a psychophysiological indicator of attention and arousal. Both have been reported to be deteriorated in schizophrenic and depressed patients. Thirty-four patients with major depression, 43 patients with schizophrenia and 49 healthy subjects were investigated during acute illness with a complex three-stimulus go/no-go task which requires different states of attention: trials consisted of three complex figures that were tachistoscopically presented. Three identical figures had to be confirmed by pressing a button (target condition). CNV was measured: (1) after the first figure waiting for the second (baseline condition), (2) after two identical figures waiting for the third (response-relevant condition), (3) after two different figures waiting for the third (response-irrelevant condition). The response-relevant condition compared to baseline significantly intensified CNV in healthy controls and to a minor extent in depressed patients but not in schizophrenics. In the response-relevant conditions in healthy controls, CNV was significantly reduced compared to the response-relevant condition. This clear discrimination between response-relevant and response-irrelevant conditions was not observed in either group of patients. Thus, the applied CNV paradigm was able to discriminate schizophrenic and depressed patients from healthy controls. Furthermore, subtle differences between schizophrenic and depressed patients were detected, reflected by the different CNV development across experimental conditions.     

精神分裂症患者家属的情感表达

目的探讨中国精神分裂症患者家属情感表达的特点。方法对Ｃａｍｂｅｒｗｅｌ家庭会谈表（ＣＦＩ）中文版的信度和效度进行检验，并用其测定成都市７１例精神分裂症患者家属的情感表达。结果ＣＦＩ中文版具有较好的信度和效度，评定者间总体评定的一致率为９０％；情感表达５个变量之间结构效度检验，Ｐ＜０．０５或＜０．０１；精神分裂症患者家属高情感表达者占２８．２％，敌视的比例为１５．５％。结论中国文化背景下家属高情感表达者较少；家属对疾病的认识可能是影响精神分裂症患者家属情感表达的重要因素     

Associated factors of rehospitalization among schizophrenic patients

The purpose of the present study was to identify the associated factors of rehospitalization in schizophrenic patients. A case-control study was conducted. The cases consisted of rehospitalized patients (n = 67) and controls selected from the outpatients who were matched by age, gender, and the period after the last discharge (n = 62). In the multiple logistic regression analysis, no clinic visits in the second month prior to entry, the number of clinic visits in the previous month, and junior high school graduation as education level were significantly (P < 0.01) associated with rehospitalization after controlling their present function as assessed by the Global Assessment of Functioning. Close monitoring of clinic visits and outreach service appear to be important in preventing rehospitalization of schizophrenic patients. These identified modifiable factors suggest further needs for development and implementation of integrated mental health services in the community.