Personality Disorders

 

 

 

Marriage counseling,Personality Disorders and others

 

 

What are the personality disorders?

 

Disorders of personality are abnormal exaggerations of normal traits, though some of these disorders also show symptoms not seen in normal people. Differences in personality between people depend on their genetic make-up and on their life experiences, and these differences show up in the relative strength of emotions and behaviors. Maladaptive personality traits can improve with psychosocial interventions and over time, though not completely. Although residual effects will remain, it is worth the effort since medical interventions are likely to fail except in very few cases.

 

The following table illustrates some of these personality traits and their maladjusted extensions:

 

PERSONALITY TRAITS

MALADJUSTED

NORMAL

NORMAL

MALADJUSTED

Expressed Traits

Very High

High

Low

Very Low

LEVEL OF ANXIETY

Fear

Worrisome

Calm

Oblivious to threat

LEVEL OF ANGER 

Rage

Defiant

Even-tempered

Does not protest when exploited

LEVEL OF  SADNESS

Depressed

Pessimistic

Not easily discouraged

Unrealistic optimism

LEVEL OF SELF-CONSCIOUSNESS

Extreme embarrassment

Self-conscious

Self-assured

Shameless

LEVEL OF IMPULSIVITY

Highly impulsive

Self-indulgent

Restrained

Over-restrained

LEVEL OF VULNERABILITY

Helpless

Fragile

Resilient

Fearless

LEVEL OF BONDING

Intense attachments

Warm

Reserved

Cold

LEVEL OF ASSERTIVENESS

Dominant

Forceful

Passive

Submissive

ENERGY LEVELS

Frantic

Energetic

Slow-paced

Lethargic

LEVEL OF EXCITEMENT-SEEKING BEHAVIOUR

Reckless

Adventurous

Cautious

Apathetic

EMOTIONAL LEVEL

Manic

Cheerful

Sober

Grim

LEVEL OF FANTASY

Unrealistic

Imaginative

Realistic

Concrete

TYPE OF BEHAVIOUR

Eccentric

Unconventional

Predictable

Mechanical

TYPE OF IDEAS

Weird

Creative

Pragmatic

Closed to new ideas

QUALITY OF VALUES

Radical

Flexible

Traditional

Dogmatic

ABILITY TO TRUST

Gullible

Trusting

Cautious

Suspicious

LEVEL OF HONESTY

Child-like

Honest

Shrewd

Manipulative

ALTRUISM

Selfless

Generous

Frugal

Greedy

COMPLIANCE LEVELS

Meek

Obedient

Critical

Combative

LEVEL OF MODESTY

Self-denigrating

Humble

Confident

Boastful

LEVEL OF COMPETENCE

Perfectionist

Efficient

Casual

Lax

LEVEL OF ORDERLINESS

Obsessive

Methodical

Disorganised

Sloppy

LEVEL OF RESPONSIBILITY

Rigidly Principled

Dependable

Easy-going

Irresponsible

LEVEL OF DRIVE

Workaholic

Diligent

Carefree

Aimless

LEVEL OF SELF-DISCIPLINE

Single-minded

Self-disciplined

Leisurely

Negligent

LEVEL OF DELIBERATION

Indecisive

Reflective

Decides quickly

Rash

LEVEL OF SOCIABILITY

Attention seeking

Sociable

Independent

Isolated

 

Stress Related disorder

  • When a person is exposed to a threat, direct or indirect, actual or anticipated, leading to a bodily experience of stress, it is called “stress experience”. These events or objects are then called “stressors”. 
  • “Stress Experience” is a physical and psychological state that promotes or impairs the adaptive capacity of a person due to the impact of a stressor mediated through the autonomic nervous system. 
  • stressor and stress experience result in a set of “stress responses”. These are reactions to their experiences. These responses can be “adaptive” or “maladaptive” causing “stress-related disorders”. 

Post-traumatic stress disorder (PTSD)

Support is given by a counselor to help the person cope with future adaptation. medications are used only if there is a threat to self or others. Relaxation, CBT (to understand how one can manage stress effectively) are modes of treatment if there is a risk of inadequate coping by the individual. Most people left alone to cope with stress quite well.

 

What is work stress?

Recent changes in expectations from the workforce, due to rapid development in technologies have increased the pace of the work, increased workloads; and increased demands for high performance, resulting in employment becoming more precarious and more insecure.      

 

 

  • Mind (Psychological aspects of stress experience that responds to medicines)
  • Behaviour (Stress responses that a person need to control by self)
  • Body (Organ responses to stress that are amenable to medications)
  • Immune system (Long-term effects of unmanaged stress experience)
  • Heart (Long-term effects of unmanaged stress experience)

 

  • Can We Eliminate Stress? 

Some degree of stress adds to better performance in life. Excessive stress, however, may make one damaged. Hence, the goal is not to eliminate stress altogether, but to cope with it and to use it to one's advantage. One needs to find the optimal level of stress that will motivate but not to overwhelm one.

There is no single level of stress that is optimal for all people. What is distressing to one may be a joy to another. If you are experiencing stress symptoms continuously and feel that it is affecting you adversely, you have gone beyond your optimal stress level; you need to reduce the stress in your life and/or improve your ability to manage it.

 

  • How Can We Manage Stress?
  • People cope with stress in a variety of ways. Some fight it, others run away from it and some use a combination of both.
  • Determine what events distress you e.g. Psychological illness, Physical illness, Family problems, Work problems.
  • Change problems that are within your power to change.
  • Avoid exposure to stressors that you cannot change.
  • Accept those you cannot avoid or change.
  • Increase control over emotional and physiological stress experience through relaxation exercises and or through the use of medicines. 

Learn to moderate your physical and psychological reactions to stress. When people learn to relax, using relaxation exercises, their overall level of autonomic arousal is reduced. People who are able to relax are also more likely to think rationally and be able to restructure their negative response to stressors.

Physical  and physiological steps to control stress experience

 

  • HOW CAN WE CHANGE MALADJUSTED RESPONSES TO STRESS?
  • Counseling

A clear understanding of stressful events and coping play a major role in determining the responses to stress. Counselling aims to help people become more aware of their experiences to stressors, educate them on how stressors negatively influence emotional and behavioural responses and teach them a variety of effective emotional and behavioural skills.

  • Medication

Medicines are of help to people who struggle with stress. Medication can be extremely effective when a major psychiatric condition like depression is present. Even in milder forms of stress, medication can be of help. Unsupervised long-term use of medication is not recommended because it can produce side effects. Untreated major stress experiences lead people to suicide in some cases. Therefore, it is necessary to detect early distress in people.

 

Gender Identity Disorder

Gender identity disorder is used to describe a male or female who feels a strong identification with the opposite sex and feels distressed because of his or her actual sex. The disorder is not because of their identity with the opposite sex, but a term to describe the emotions resulting from such identification. They are uncomfortable with their present sexual role and have a desire to alter their bodies. Causes of gender identity disorder are not fully known even today. A mismatch between the body and an internal sense of gender is not a mental illness. One of the most common questions that parents of children with gender identity disorder ask is, "Is it just a phase?" Unfortunately, there is no way to know for sure. Not all young children who feel this way do feel so in their adulthood.

 

Gender identity disorder entered the psychiatric nomenclature in the DSM-III in 1980. It was traditionally thought to be a psychiatric condition meaning a psychiatric disease. Current research suggests that development that determines biological sex happens in the mother’s womb. Anatomical sex is determined by chromosomes that contain the genes and DNA. During early pregnancy, all unborn babies are female because only the female sex chromosome inherited from the mother is active. After the eighth week of pregnancy, the chromosome from the father becomes active. If the father contributes an X chromosome, the baby develops as a female. If the inherited chromosome from the father is a Y  the fetus develops male characteristics. There are several other causes of gender differences, including hormonal changes, exposure to drugs related to sex hormones etc. For example, if there are excess female hormones generated in the mother with a male fetus, anatomical sex from the genitals may appear to be male, while the gender identity that comes from the brain could be female. Similarly, exposure to progesterone or other estrogenic drugs may be associated with atypical gender role behavior. There are also chromosomal abnormalities that lead to gender identity. Sexual orientation is partly heritable in men, thanks to studies of families in which some people are straight and some people are gay. There are probably multiple genes involved, each with a fairly low effect, that will increase the chances of some being gay. There is no substantive evidence to suggest parenting or early childhood experiences play a role in sexual orientation.

 

There are three main categories of sexual orientation within the heterosexual–bisexual-homosexual continuum. Homosexuality is a romantic attractionsexual attraction or sexual behavior between members of the same sex. It is an enduring pattern of emotional, romantic, and/or sexual attraction to people of the same sex. The relationships of a person with gender identity spectrum are equivalent to heterosexual relationships in essential psychological respects. Homosexual relationships and acts have been admired or condemned, depending on the form they took and the culture in which they occurred. A term transgender is used to describe someone who feels his or her body and gender do not match with each other. Transvestism is the practice of dressing and acting in a style or manner traditionally associated with the opposite sex.

 

Some of the questions that are commonly asked for confirmation of adult homosexuality are as follows. Do you feel strongly that your gender identity is at odds with your biological sex? Do you often feel that your feelings and reactions towards another person are more in line with how someone of the opposite gender would feel or act? Are you currently dating, sexually active or in a relationship(s)? There can be many variants of these questions for practical use.

 

Treatment for people with gender identity disorder focuses on treating depression and anxiety and improving self-esteem. Many people do not see their gender identity disorder symptoms as requiring treatment. People with gender identity disorder request hormone and surgical treatments to suppress their biological sex and acquire those characteristics of the opposite sex. Because of the irreversible nature of the surgery, candidates for sex-change surgery are evaluated extensively and are often required to spend a period of time before integrating themselves into the cross-gender role before the procedure begins. Significant social, personal, and occupational issues may result from surgical sex changes, and the patient may require psychotherapy or counseling after the change too. Available information seems to indicate that reparative therapy is ineffective.

 

Many people feel attracted to people of the same sex. For some people, these feelings can be very intense. Some people find that these feelings change over time. Some of them are bisexual, meaning they are attracted to both men and women and have relationships with both. Some people are not attracted to anyone. With time, someone who is homosexual will realize that not only are they sexually attracted to members of the same sex, but that this attraction is not transitional. However, for some people, homosexual experiences are part of a transitional or experimental phase in their youth.

 

 Coming to terms with confusion about identity can have both positive and negative effects on many aspects of a person's life, including social relationships, work, and self-esteem. It can take a long time too. Coming to terms is not a single action. It is a process that begins with a feeling of being 'different' to other people of the same sex. Sometimes they recognize that they are not very interested in people of the opposite sex but more often they feel they are not really interested in things which are supposed to be appropriate for their sex. Different people cope with the emotional upheaval of identity confusion in different ways. Some people deny it to themselves and try to avoid thoughts and feelings which may confirm they are homosexual. Others persevere with heterosexual relationships to try and 'convert' themselves. In some extreme cases, people may try to avoid confronting their feelings by expressing strong homophobia or turning to drink and drugs in order to find temporary relief from them.

 

Making the decision to tell others that you are homosexual, bisexual or transgender can relieve a great deal of stress and unhappiness and build self-esteem, as well as help improve relationships. However, there are also risks associated with telling others, and it is important to think carefully about how you could cope with the potential consequences of telling others. Friends and family may not react in an understanding way, and relationships can be changed significantly. Having time to fully come to terms before telling others can mean you are more prepared to deal with any misunderstanding or prejudice you may face. Telling others does not mean that you have to tell everybody. Many people chose to tell first to people who they think are more likely to react positively. It not only helps them get an idea of how people may react but often means that they will have someone to support them when they tell others. Some people may never be able to accept your true gender identity. This is not something that you can change, and it can be very hard to feel rejected by someone you are close to.

 

There are also many stereotypes surrounding homosexual relationships. As with heterosexual couples, homosexual relationships can also be short-lived or long-term. Many relationships get strained sometime during life, resulting in poor functioning and producing self-reinforcing, maladaptive patterns. There are many possible reasons for this, including insecure attachment, ego, arrogance, jealousy, anger, greed, poor communication or poor problem-solving skills, ill health, third-party influences and so on. Changes in situations like financial state, physical health etc. also have a profound influence on the actions of the individuals in a relationship. Often, it is the interaction between people, rather than the behavior of just one person that causes such maladaptive conflicts. These need to be explored collaboratively and discussed openly so that the core values can then be understood and changed when no longer appropriate. This implies that each person takes equal responsibility for awareness of the problem as it arises, awareness of their own contribution to the problem and making some fundamental changes in thought and feeling. The next step is to adopt conscious changes to the inter-personal relationships and evaluate the effectiveness of those changes over time. Counseling focuses on clearing past issues that continue to affect your present situation while developing new skills to solve your current issues. It replaces resentment with respect and replaces arguments with caring responses. New skills build intimacy without sacrificing one's individual identity. Working individually and together, people can heal old wounds, gain the abilities to addresses conflicting priorities and betrayal of trust.

Common signs of relationship problems:

1.The feeling of having grown apart

2.Arguments, nagging or angry silence

3.Lack of intimacy and affection

4.Persistent and unresolved problems

5. Feeling unappreciated

6. One's needs are not appreciated by the partner

7. Communication becomes one-sided, hostile, sarcastic, angry or absent.

8. Partners spend little or no time alone

9.Trust issues – dishonesty/lies, affairs, unexplained absences, secrecy regarding email, phone and text message.

It is also more 'here and now' and deals with new coping strategies and about seemingly intractable problems within a relationship. These sessions also encourage the client to make steady progress in a caring and supportive manner.

 

Counseling for Same-Sex Relationships

Infidelity, intimacy or sexual concerns, difficulty in communicating – same-gender couples experience the same relationship issues as heterosexual couples. There can also be added difficulty of maintaining a strong relationship within a society that is hostile.

 

Relationship counseling for gay couples gives you a non-judgemental environment in which to explore your relationship. In same-sex relationships, couples have a high level of initial rapport and understanding. It can add to the emotional intensity in the beginning. However, when this initial phase ends and the early passion lessen. Then there is a feeling of disillusionment and fear that things won’t work out. In addition, how open and expressive one partner is of their sexuality may be in conflict with that of their partner. There may also be difficulties with being close, with one partner longing for closeness and the other finding closeness suffocating. 

 

 

 

MARRIAGE COUNSELING

Stages of Marriage

A marriage is a relationship that moves through different phases and develops certain common patterns:

 

Passion

This stage happens at the beginning of the relationship and is characterized by intense romance and attraction.  It is a relatively short-lived phase and lasts for a brief duration in the beginning.

 

Realisation

After the initial passion, it begins to fade. There is a more realistic vision of their life together. In this phase, each person sees their partner as a human being,  with flaws and shortcomings. Disappointment sets in.

 

Rebellion

In this phase, each partner’s self-interest comes to the fore. They lead to power struggles. Anger and frustration, and cause major rifts in the marriage.

 

Cooperation

When different life stressors appear in their day-to-day life, intimacy is put on the back burner and couples work on managing their lives.

 

Reunion

After children have left them couples rekindle their relationship as friends.

 

Disruption

In this phase, the couple faces serious life situations and they deal with them together. During this time, the couple can become closer or drive themselves apart. It can occur at any time in a marriage.

 

Old age

In this stage, the couples explore a new life together.

 

While divorce may be necessary for some, others may wish to try to salvage whatever is left of the marriage. Here are the good reasons for meeting a psychiatrist for marriage counseling.

 

  • Communication has become negative. Negative communication can be due to one partner feeling depressed with psychiatric illness, an introverted personality, insecurity and so on. Negative communication also includes physical abuse, as well as other nonverbal communications.
  •  When one or both partners consider having an affair, or one partner has had an affair.
  • When the couple seems to be “just occupying the same space.” When couples become more like roommates than a married couple, this may indicate a need for counseling.
  •  When the partners do not know how to resolve their differences.  If a couple is stuck due to very stubborn personality traits, suspiciousness or obsessive-compulsive disorder, a psychiatrist may be able to get them moving in the right direction.
  •  When one partner begins to act out on negative feelings.
  • When the only resolution appears to be separation. Spending time away from home does not usually resolve the situation. Instead, it reinforces the thought that time away is helpful, often leading to more absences.
  •  When a couple is staying together for the sake of the children. Children are generally very intuitive and intelligent. No matter how couples may think they are able to fake their happiness, most children are able to tell.

 

 

All marriages are not salvageable in the process of marriage counseling, some couples may discover it is healthier for them to be apart. 

 

Marriage is a social and legal contract between people to create an institution in which interpersonal, emotional and sexual relationships, are acknowledged in a culturally appropriate manner. It includes arranged marriages, marriages out of family obligations, marriages to establish a legal nuclear family, marriages for legal protection of children or public declaration of commitment to each other and so on. 

 

Individuals in a relationship also come with different value systems. Hence, societal factors like the social, religious, group and other factors that shape a person's behavior are also considered while counseling. It is advantageous for all in relationships to interact with each other and their society with minimal amounts of conflicts.

 

Many relationships get strained sometime during life, resulting in poor functioning and producing self-reinforcing, maladaptive patterns. There are many possible reasons for this, including insecure attachment, ego, arrogance, jealousy, anger, greed, poor communication or poor problem-solving skills, ill health, third-party influences and so on. Changes in situations like financial state, physical health, and the influence of other family members can also have a profound influence on the actions of the individuals in a relationship. Often, it is the interaction between people, rather than the behavior of just one person that causes such maladaptive conflicts.

 

Relationship influences are reciprocal and it takes all the people involved, to manage problems in a marriage. A solution to the problem and setting relationships back on track requires a reorientation of perceptions and emotions of all people concerned. These need to be explored collaboratively and discussed openly so that the core values can then be understood and changed when no longer appropriate. This implies that each person takes equal responsibility for awareness of the problem as it arises, awareness of their own contribution to the problem and making some fundamental changes in thought and feeling. The next step is to adopt conscious changes to the inter-personal relationships and evaluate the effectiveness of those changes over time.

 

 Counseling focuses on clearing past issues that continue to affect your present situation while developing new skills to solve your current issues. It replaces resentment with respect and replaces arguments with caring responses. New skills build intimacy without sacrificing one's individual identity. 

 

Common signs of relationship problems:

1.The feeling of having grown apart

2.Arguments, nagging or angry silence

3.Lack of intimacy and affection

4.Persistent and unresolved problems

5 Feeling unappreciated

6 One's needs are not appreciated by the partner

7 Communication becomes one-sided, hostile, sarcastic, angry or absent.

8 Partners spend little or no time alone

9.Trust issues – dishonesty/lies, affairs, unexplained absences, secrecy regarding email, phone and text message.

 

Marriage counseling It is also more 'here and now' and deals with new coping strategies about seemingly intractable problems within a relationship. These sessions also encourage the client to make steady progress in a caring and supportive manner. During marriage counseling, regardless of the origin of the problem and whether the clients consider it an "individual" or "family" issue, involving all partners in solutions is often beneficial.

 

 Couple therapy can explore what is lacking in your current relationship and solve the problem.

 

1. Your counselor will be interested in your current problems and issues in your relationship.  “What’s it that brought you here today?”

 

2. Your counselor will inquire about how your relationship started. what’s drawn the couple to be together?  Why did they choose each other? Under what circumstances did they meet?

 

3. Your counselor will want to know about some of your individual histories. Are there any important historical issues that may have affected your life.

 

4. Your counselor will ask you what kind of relationship you desire. It’s important that you share what type of relationship you want to create with your partner.

 

5. Your counselor will be looking for your strengths as a couple.

 

6. Your counselor will ask you about your individual relationship blocks to know what you need to start doing differently to improve your relationship.

 

7. Your counselor will ask you to relate in a different way during the session to bringing about change in the relationship.

 

8. Your counselor will be giving you live feedback.

 

9. Your counselor will give you awareness homework for outside of the session.

 

10. Your counselor will regularly review your work.

 

A VERY IMPORTANT ASPECT TO BE REMINDED BEFORE ONE STARTS A MARRIAGE COUNSELLING IS TO CONSULT A PSYCHIATRIST, TO RULE OFF ANY POTENTIAL PERSONALITY PROBLEM OR PSYCHIATRIC ILLNESS IN THE PARTNERS THAT CAN BE EASILY TREATED. MANY FAMILIES BREAK UP BECAUSE OF A TREATABLE PROBLEM IN ONE OR BOTH PARTNERS. HENCE BOTH PARTNERS NEED TO ATTEND THE PSYCHIATRIC EVALUATION TOGETHER.

 

 

BIPOLAR DISORDERS: CLICK HERE FOR MORE DETAILS

 

Hyponatremia?

(This write up is only for technical people)

Hyponatremia refers to a low level of sodium in the blood. Hyponatremia is more common in older adults because they're more likely to take medications or have medical conditions that put them at risk of the disorder. 

 

Hyponatremia may result from:

  • Excess fluid in the body relative to a normal amount of sodium
  • Consumption of excess water, without adequate replacement of
    sodium.
  • Kidney failure (when excess fluid cannot be efficiently excreted)
  • Congestive heart failure, in which excess fluid accumulates in the body
  • SIADH (syndrome of inappropriate anti-diuretic hormone) is a disease whereby the body produces too much anti-diuretic hormone (ADH), resulting in retention of water in the body
  • Due to a loss of sodium and body fluid
  • During prolonged sweating and severe vomiting or diarrhea.
  • Medical conditions that can be associated with hyponatremia
  •  Adrenal insufficiency
  • Hypothyroidism
  • Cirrhosis of the liver
  • Certain cancers, including lung cancer
  • Medications that lower blood sodium levels
  • Diuretics: particularly thiazide diuretics, including combinations with angiotensin-converting enzyme inhibitors and angiotensin receptor antagonists
  • Antidepressants: selective serotonin reuptake inhibitors, monoamine oxidase inhibitors, venlafaxine
  • Antipsychotics: phenothiazines, haloperidol
  • Antiepileptic's: carbamazepine, oxcarbazepine, valproate, lamotrigine
  • Antidiabetics: chlorpropamide, tolbutamide
  • Antibiotics: ciprofloxacin, trimethoprim-sulfamethoxazole, rifabutin
  • Antiarrhythmic: amiodarone
  • Antihypertensive: angiotensin-converting enzyme inhibitors (angiotensin receptor antagonists), amlodipine
  • Anticancer/chemotherapeutic drugs: vincristine/vinblastine, cisplatin/carboplatin, alkylating agents, methotrexate, levamisole
  • Proton pump inhibitors
  • Non-steroidal anti-inflammatory drugs
  • Oxytocin, antidiuretic hormone analogs
  • Amphetamines: MDMA (ecstasy)

 

Symptoms

Symptoms are nonspecific and can include a headache, altered mental state, seizures, and decreased consciousness which can proceed to coma and death. Other possible symptoms include restlessness, muscle spasms or cramps, weakness, and tiredness. Nausea and vomiting may accompany any of the symptoms. Therefore, monitoring of serum sodium levels is very important. Hyponatremia is the most commonly encountered electrolyte disorder in clinical practice.

 

  • Hypovolemic hyponatremia is usually seen in patients presenting with severe diarrhea or vomiting and urine sodium values <30 mmol/L.
  • In euvolemic patients, hyponatremia is most often due to SIADH, and patients typically have urine sodium levels >40 mEq/L. Patients presenting with SIADH are usually asymptomatic unless the sodium level is below 120 mEq/L.7 Free water excretion is impaired in SIADH, as evidenced by urine osmolality levels >100 mOsm/kg. SIADH is often a diagnosis of exclusion.
  • When differentiating between SIADH and psychogenic polydipsia, it is important to measure serum sodium, osmolality, and urine osmolality. Patients with psychogenic polydipsia may present with impaired mental status and further exacerbation of anxiety symptoms. Patient symptoms may include urinary incontinence, including enuresis. 

Hyponatremia is seen in about 4% of patients with chronic schizophrenia and occasionally in patients with other psychiatric disorders.

  • Psychotropic drugs may cause the sensation of a dry mouth, which may contribute to increased water intake. Causality between psychotropic agents and hyponatremia has been shown more persuasively with selective serotonin reuptake inhibitors (SSRIs). With respect to SSRI-induced SIADH, cross-sensitivity among agents has been reported.
  • Hyponatremia caused by SIADH is due to increased release of antidiuretic hormone (ADH). SIADH has been associated with many drugs and others, including nicotine, barbiturates, carbamazepine, and antipsychotics such as fluphenazine, thiothixene, and phenothiazine. Fluoxetine is the SSRI most commonly reported to cause hyponatremia and SIADH. Current evidence suggests a relatively higher risk of hyponatremia with SSRIs and venlafaxine. Incidence figures for mirtazapine and tricyclic antidepressants were lower, supporting the use of these drugs as an alternative therapy.  Any medications that may cause nephrogenic diabetes insipidus (such as lithium) may require discontinuation. It is important for healthcare practitioners to differentiate between drug-induced SIADH and psychogenic polydipsia. 
  • Alcohol abuse is common in psychiatric patients, and often these patients present with hyponatremia.

 

Investigations

The normal blood sodium level is 135 - 145 milliEquivalents/liter (mEq/L).

Renal function and electrolytes

 

  • Low sodium with normal renal function indicates dilutional hyponatremia either euvolemic or hypervolemic, hypovolaemic especially if serum urea is low.
  • Impaired renal function, especially with elevated serum urea hypovolemic hyponatremia.
  • high serum potassium suggests chronic renal disease or if the urea and creatinine concentrations are only mildly elevated, hypocortisolaemia.

 

  • Osmolality

Serum osmolality will be low in all cases of hyponatremia except for the rare cases of isotonic or hypertonic hyponatremia. The appropriate physiological response to dilutional hyponatremia is to maximize water excretion by passing maximally dilute urine. The maximal excretion capacity of the kidney is 10-15 L per day and maximally dilute urine has an osmolality of less than 100 mmol/kg. In a patient with dilutional hyponatremia and normal renal function, urine osmolality greater than 100-150 mmol/kg indicates lack of appropriate suppression of antidiuretic hormone or an inability to maximally dilute the urine due to other mechanisms such as diuretic therapy.

If investigations suggest a diagnosis of syndrome of inappropriate antidiuretic hormone secretion, further investigations to identify intracranial or intrathoracic pathology or occult malignancy at another site are required.

 

  • Urine sodium

The clinical assessment of hydration status is frequently inaccurate so urinary sodium is an important measurement as it assists in the differentiation of the hypovolaemic from the euvolaemic patient. Urine sodium under 20 mmol/L indicates hypovolaemic hyponatremia where the sodium loss is of extra-renal origin as the kidneys are reabsorbing sodium. Patients with hypervolemic hyponatremia due to cardiac failure, cirrhosis or nephrotic syndrome without renal failure may also have low urinary sodium.

urine sodium above 20 mmol/L indicates euvolemic hyponatremia of any cause. The urinary concentration of sodium is usually high because of the relatively low urine volume passed in these conditions. High urinary sodium concentrations can also be seen in hyponatremia associated with renal salt wasting and renal failure, and in patients on diuretic therapy.

 

  • Endocrine tests

Thyroid function tests to exclude hypothyroidism as a cause of hyponatremia. The possibility of hypopituitarism and Addison's disease should be considered in the differential diagnosis of hyponatremia. If there is clinical suspicion, measure morning cortisol and adrenocorticotrophic hormone (ACTH), with or without a short ACTH stimulation test.

 

Hyponatremia treatments

Hyponatremia treatments include changing a medication that affects your sodium level, treating the underlying disease, changing the amount of water you drink, or changing the amount of salt in your diet. Treatment of severe hyponatremia involves intravenous fluid and electrolyte replacement, medications to manage the symptoms of hyponatremia, as well as any treatments for the underlying cause.

 

  • How to Raise Sodium Levels in the Blood

Reduce your intake of water to raise your sodium levels in your blood. Drinking less water will prevent dilution and raise the concentration of sodium in your blood stream.

Drink a sports drink/Orange juice/Electoral that contains sodium.

Add additional salt to the foods you eat to increase the sodium levels in your blood stream. Principal causes of drug-induced hyponatremia

 

Severity is assessed by the patient's volume status is classified as hypervolemic (increased total body water), euvolemic (increased total body water but not clinically significant on physical examination), or hypovolemic (low total body water).

 

  • Euvolemic hyponatremia

While fluid restriction is the initial treatment of choice in asymptomatic patients, more active and urgent treatment is required in the symptomatic patient with severe euvolemic hyponatremia. It is the commonest type of severe hyponatremia and prompt intervention to raise the serum sodium is indicated. Isotonic saline is contraindicated as it can be associated with a further fall in serum sodium. Hypertonic saline should only be used in symptomatic patients with very low serum sodium concentrations. The infusion aims to increase the serum sodium to a 'safe' level, usually considered to be greater than 120-125 mmol/L depending on the initial concentration. The rate of increase in serum sodium should be limited to prevent complications. A recent review has suggested that immediate treatment should be the infusion of 100 mL of 3% sodium chloride over one hour. If symptomatic hyponatremia with fitting persists, a further 200 mL over the next two hours can be given. The aim of treatment is to raise the serum sodium into a 'safe' range usually recognized as greater than 120 mmol/L and to abolish the patient's symptoms. Once these goals have been achieved further hypertonic saline should not be given, although ongoing fluid restriction will usually be required. It may take 48-72 hours for the patient's symptoms to improve. The maximum rate of increase in serum sodium should not exceed 10 mmol/L over 24 hours and 18 mmol/L over 48 hours to minimize the risk of osmotic demyelination. In patients with liver disease, a slower rate of correction is indicated in view of their greater risk of osmotic demyelination. Hypertonic saline can only be administered safely in a hospital with intensive care facilities associated with 24-hour onsite pathology, as the patients must be closely monitored and have their electrolytes checked every two hours. However, the initial infusion of hypertonic saline may need to be given before transfer to that higher level care.

 

  • Hypovolemic hyponatremia

Treatment consists of volume expansion with isotonic saline. This is the only situation in which the use of isotonic saline is an appropriate treatment for hyponatremia.

 

  • Hypervolaemic hyponatremia

Cardiac failure, hepatic cirrhosis or renal disease should be easily recognizable by history, clinical examination and the results of renal and liver function tests. The management is to treat the underlying disease process and will usually include fluid restriction and diuretic therapy.

 

Complications of treatment

The treatment of hyponatremia has been a controversial topic largely due to the recognition of cerebral demyelination ('central pontine myelinolysis', 'osmotic demyelination') as a specific pathological entity associated with hyponatremia and with the rate and extent of the correction of serum sodium in these patients.

 

Excessively rapid restoration of serum sodium and 'overcorrection' of serum sodium above the normal range have been associated with cerebral demyelination which is irreversible and frequently fatal, and may not be evident for several days after treatment has been completed. The patient recovering from hyponatremia may deteriorate unexpectedly. Depending on the area of the brain affected, a variety of neurological or psychiatric symptoms may develop.

 

Dementia

 

Mild Dementia

In the early stage of dementia, an individual can still function independently and is still able to drive and maintain a social life. In the very early stage of dementia, symptoms that are seen may be attributed to the normal process of aging. For instance, there might be slight lapses in memory, such as having difficulty finding the word for something or misplacing eyeglasses. Other difficulties may include issues with planning, organizing, concentrating on tasks, or accomplishing parts of employment. This early stage lasts between 2 and 4 years.

 

Moderate Dementia

The middle stage of dementia is the longest stage of the disease, brain damage is extensive enough that a person has trouble expressing their thoughts, performing daily tasks, and has more severe memory issues than in the earlier stage. An individual in this stage do not remember the address, unable to recall personal history, and get confused as to location. Communication becomes difficult and lose track of thoughts,  unable to follow conversations, and have trouble understanding what others are trying to communicate. Behavior changes, such as aggressiveness, difficulty sleeping, depression, paranoia, repeating actions and/or words, hoarding, anger, wandering, incontinence, and frustration are visible. This stage of dementia lasts between 2 and 10 years.

 

Severe Dementia

In late-stage dementia, individuals have significant issues with communication, often using only words or expressions. At the very end, they may not verbally communicate at all. Memory also worsens and individuals may not be able to remember what they had for lunch, recall who family members are, or they may think they are in a different time period. Individuals will require extensive assistance with daily living activities. At the very end of this stage, the individual will be bedridden. This severe stage of dementia lasts approximately 1 to 3 years.

 

Care Requirement

Initially, an individual does not require care assistance, but as the disease progresses care will be needed. Eventually, the individual will not be able to care for herself at all.  Many people hire someone to provide care. There are many options, such as in-home care, adult day care, and hospital care.

 

Early Stage Dementia

In the early stage, a person can still function independently. Simple reminders of appointments and names of people may be needed. Coping strategies include writing out a daily to-do list. During this period discuss and make decisions about the future.

 

Middle Stage Dementia

In the middle stage, an individual no longer is able to function as independently as in the earlier stage. Assistance with activities of daily living is often required. Initially, an individual may only need prompts. However, at some point, more hands-on assistance will be required. Establishing a routine becomes important. Since individuals In this stage, it is not safe to leave the individual alone without supervision.

 

Late Stage Dementia

A person in this last stage requires supervision is required 24-hours / day. Patients require assistance getting in and out of bed, moving from the bed to a chair, or maybe bedridden and require help moving positions to avoid bedsores. Swallowing becomes difficult in late stage dementia, and food needs to be cut into small pieces and is soft. At some point, the individual will be 100% dependent on their caregiver.

 

  • Make time for regular exercise to minimize restlessness.
  • Consider installing new locks high or low on the door; many people with dementia will not think to look beyond eye level.
  • Try a barrier like a curtain to mask the exit door.
  • Consider installing a monitoring system to keep watch over someone with dementia.
  • Always have a current photo available should you need to report your loved one missing.
  • Tell neighbors about your relative’s wandering behavior, and make sure they have your phone number.
  • Establish a routine for using the toilet.
  • Schedule fluid intake to ensure the confused person does not become dehydrated.
  • Limit fluid intake in the evening before bedtime.
  • Use signs (with illustrations) to indicate which door leads to the bathroom.
  • A commode can be left in the bedroom at night for easy access.
  • Incontinence pads can be purchased at the supermarket.
  • Use easy-to-remove clothing with velcro closures, and provide clothes that are easily washable.
  • Reduce noise and clutter in the room.
  • Keep objects and furniture in the same places in the room.
  • Reduce caffeine intake, sugar, and other foods that cause spikes in energy.
  • Try gentle touch or walks to quell agitation.
  • Keep dangerous objects out of reach.
  • Allow the person to do as much for himself as possible
  • Confronting a confused person may increase anxiety.
  •  Provide plenty of reassurance, in words and in touch.
  • Avoid reminding them that they just asked the same question.
  • Don’t discuss plans until immediately prior to an event.
  • If the person suspects money is “missing,” allow her to keep small amounts of money in a pocket or handbag for easy inspection.
  • Help them look for the “missing” object and then distract them into another activity.
  • Explain to helpers that suspicious accusations are a part of the illness.
  • Increase daytime activities, particularly physical exercise.
  • Plan smaller meals throughout the day and a light meal before bedtime.
  • Turn on lights well before sunset and close the curtains at dusk to minimize shadows.
  • Sleeping pills solve the problem of getting sleep at night but make the person confused the next day.
  • It’s essential that the caregiver gets enough sleep. If the dementia patient keeps caregiver awake at night, consider hiring someone to take a turn. 
  • Try using a straw or a child’s “sippy cup” if holding a glass is difficult.
  • If loss of weight is a problem, offer high-calorie snacks between meals.
  • Use safety features such as non-slip bath mats, grab-bars, and bath or shower seats. A hand-held shower might also be good to install.