Hypomanic psychosis precipitated by hemodialysis

Medical Psychology and Psychonephrology: Contributions of Clinical Psychology

Clinical psychology is developing into an integral part of modern health care delivery systems as evidenced by its role in the establishment of services in clinical psychology in general hospitals, training programmes in medical psychology, and the increased teaching of medically applied psychology in medical schools. This extended role of clinical psychology is discussed against the background of a subspecialization in psychonephrology. The aim is to illustrate the development of psychological treatment for chronically ill patients with end-stage renal disease, in the context of a developing country with a multi-ethnic society.

Mania secondary to focal brain lesions: implications for understanding the functional neuroanatomy of bipolar disorder

OBJECTIVES

Approximately 3.5 million Americans will experience a manic episode during their lifetimes. The most common causes are psychiatric illnesses such as bipolar I disorder and schizoaffective disorder, but mania can also occur secondary to neurological illnesses, brain injury, or neurosurgical procedures.

METHODS

For this narrative review, we searched Medline for articles on the association of mania with stroke, brain tumors, traumatic brain injury, multiple sclerosis, neurodegenerative disorders, epilepsy, and neurosurgical interventions. We discuss the epidemiology, features, and treatment of these cases. We also review the anatomy of the lesions, in light of what is known about the neurobiology of bipolar disorder.

RESULTS

The prevalence of mania in patients with brain lesions varies widely by condition, from <2% in stroke to 31% in basal ganglia calcification. Mania occurs most commonly with lesions affecting frontal, temporal, and subcortical limbic brain areas. Right-sided lesions causing hypo-functionality or disconnection (e.g., stroke; neoplasms) and left-sided excitatory lesions (e.g., epileptogenic foci) are frequently observed.

CONCLUSIONS

Secondary mania should be suspected in patients with neurological deficits, histories atypical for classic bipolar disorder, and first manic episodes after the age of 40 years. Treatment with antimanic medications, along with specific treatment for the underlying neurologic condition, is typically required. Typical lesion locations fit with current models of bipolar disorder, which implicate hyperactivity of left-hemisphere reward-processing brain areas and hypoactivity of bilateral prefrontal emotion-modulating regions. Lesion studies complement these models by suggesting that right-hemisphere limbic-brain hypoactivity, or a left/right imbalance, may be relevant to the pathophysiology of mania.

Suicide risk in dialysis: review of current literature

BACKGROUND

Studies have shown that patients with end-stage kidney disease (ESKD) are at risk of experiencing suicidal ideation and suicide attempt.

STUDY DESIGN

The aim of the present review was to investigate whether there was a relationship between dialysis and suicide. A careful systematic review of the literature was conducted to determine the potential association between dialysis and suicide.

SELECTION CRITERIA FOR STUDIES

Abstracts that did not explicitly mention suicide and dialysis were excluded. We identified as specific fields of interest in the analysis of dialysis or ESRD and suicidal behavior.

RESULTS

A total of 26 articles from peer-reviewed journals were considered and the most relevant articles (N = 13) were selected for this review.

OUTCOMES

It has been posited that suicidal ideation, occurring in dialysis, may arise from co-morbid depression and psychiatric symptoms are frequent in patients who underwent dialysis.

LIMITATIONS

The present review should be considered in the light of some limitations. We did not carry out a meta-analysis because data from most of the studies did not permit it. Samples included different measurements and different outcomes, and they assessed patients at different time points.

CONCLUSIONS

The available data suggest that the risk of self-harm may be higher than expected in dialysis patients especially in those who suffer by depression and anxiety. Moreover, although the majority of deaths among dialysis patients is preceded by withdrawal from treatment, suicide remains a separate phenomenon.

Organic mood disorder, manic type, associated with hyponatremia: a case report

OBJECTIVE

Mania and other mood changes are known to be associated with various organic etiologies. This article documents a case of organic mania associated with hyponatremia, a phenomenon which has not been previously reported, and reviews the pertinent medical literature.

METHOD

The mental status of a patient with end stage renal disease and no previous psychiatric history who presented with mania and hyponatremia was carefully monitored while her serum sodium concentration was corrected.

RESULTS

The manic symptoms of the patient presented resolved completely with correction of serum sodium concentration alone.

CONCLUSIONS

The acute episode of hyponatremia experienced by this patient with chronic, end stage renal disease appears to have precipitated the symptoms of mania. This observation may shed some additional light on the pathophysiology of organic mania.

Organic manic syndrome associated with advanced uraemia due to polycystic kidney disease

Mania secondary to advanced uraemia caused by polycystic disease of the kidneys in a 62-year-old woman involved a complex interplay of physical, psychological and social factors. Psychotherapy and thioridazine led to full recovery.

Organic causes of mania

Manic syndromes have many neurologic, toxic, and metabolic causes. It is important for clinicians to be able to distinguish these organic disorders from primary idiopathic mania (bipolar disorder). The cardinal symptom of organic mania is an abnormally and persistently elevated or irritable mood. Organic mania usually develops in patients who are older than 35 years of age, whereas bipolar disorder generally has its onset between late adolescence and age 25 years. In patients with the first episode of mania, the clinician should thoroughly elicit information about current symptoms, recent infections, use of drugs, and past or family history of psychiatric disorders. In addition, a complete medical examination, computed tomography of the head, electroencephalography, and screening for drugs and toxins should be done. Treatment of organic mania includes correcting the underlying disorder when possible.

Psychopathology of chronic haemodialysis: is it a behavioural cognitive continuum?

Neuropsychiatric complications of chronic renal haemodialysis cover a wide gamut of clinical syndromes. These pictures can be diagnostically classified as non-psychotic and psychotic-like syndromes. On the basis of a review of the literature, some nosological precisions are formulated, and a hypothesized cognitive-behavioural psychopathological continuum is presented. The hypothesis postulates that a central cognitive disturbance, due to multiple organic aetiopathogenic factors, results in a step-wise decline, initially disguised as an affective, neurotic or personality disorder, and further deteriorating into the well-known "dialysis dementia", with a variety of other clinical presentations in between. Additional research in the biological and psychosocial areas is needed to verify different aspects of these conditions, their validity in the context of the authors' hypothesis, and their relevance to the overall "quality of life" of chronic haemodialysis patients.

Organic delusions: phenomenology, anatomical correlations, and review

Organic delusions are common, but have received little systematic study. Review of the literature reveals that they occur most commonly in toxic-metabolic processes and in disorders affecting the limbic system and basal ganglia. A prospective study of 20 consecutive patients with organic delusions revealed four general types of false beliefs: simple persecutory delusions, complex persecutory delusions, grandiose delusions, and those associated with specific neurological defects (anosognosia, reduplicative paramnesia). Simple delusions responded best to treatment, and complex delusions were more resistent. Acting on delusional beliefs was not unusual, and treatment of the delusions was an important aspect of management of the patient.

Dialysis encephalopathy: a review

Dialysis encephalopathy (DE) is a distinct neuropsychiatric syndrome typically occurring in patients undergoing longterm hemodialysis. It is characterized by electroencephalographic abnormalities in association with disturbances of speech, cognition, movement, affect, or behavior. Previously thought to be relentlessly progressive, recent evidence linking the illness to aluminum overload has led to advances in prevention and treatment. Early diagnosis aids in the reversal or amelioration of the syndrome and can be of immense value to the patient, the family and involved health personnel. The general features of the syndrome, etiologic considerations, differential diagnosis and treatment are discussed. Three case studies are included to illustrate salient features of the syndrome.

Psychosis and pseudo dementia associated with hemodialysis

A patient treated with hemodialysis developed psychotic episodes, including visual hallucinations and delusions, as well as symptoms similar to the fatal dialysis dementia. His hospital course seems to demonstrate an original organic dysfunction with behavioral sequelae that were perpetuated by psychological difficulties. His tendency to overdramatize his disability and to adopt an excessively helpless and passive role made treatment difficult. A one-year followup is provided along with a discussion of the relationship of his case to dialysis dementia.

Psychiatry and medical progress: therapeutic considerations

Advances in medical technology have spurred interest in psychosocial adaptation to newer procedures, such as cardiac operations, chronic hemodialysis and renal renal transplantation. In spite of this interest, investigators have paid little attention to psychotherapeutic measures involved in the care of patients undergoing these procedures. This presentation reviews the available work in this area and brings together common themes related to the preparation and psychological treatment of these patients. These themes center around the importance of a continuous relationship with the patient which begins in the preoperative and pretreatment phase, the value of exploring in a nonthreatening fashion conflicts and fears aroused by the procedure, the need to counteract the non-human and impersonal aspects associated with medical progress, and the role of psychiatrist as the mediator between the patient and those involved in his care.

The use of dialysis bath fluid as a vehicle for a drug with a narrow therapeutic index--lithium chloride

A patient requiring regular haemodialysis treatment (RDT) for end stage chronic pyelonephritis, with a recurrent manic-depressive illness was successfully treated with lithium chloride by adding it to the dialysate, when other routes had failed.

Survival by machine: the psychological stress of chronic hemodialysis

The prolongation of life by artificial means is a compelling topic for the physician who treats patients with chronic hemodialysis. This paper discusses the stresses, losses, and restrictions which dialysis imposes upon the patient, his family, and other caretakers. Examples of psychological reactions to such circumstances are given and major conflictual problems are described. The role of dependency and independence in chronic illness, the use of denial as a major defense mechanism, alterations in body image, attitudes towards life and death are all discussed in terms of the psychological reactions to the stress of hemodialysis. The problem of suicide is illustrated with a variety of forms it takes in these special patients who depend upon mechanical devices for their very existence. Some of the moral, ethical and economic problems of patient selection for hemodialysis are indicated and briefly examined.