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Polydipsia and water intoxication in psychiatric patients: A review of the epidemiological literature

  • Jose de Leon
    Correspondence
    Address reprint requests to Jose de Leon, MD, Medical College of Pennsylvania/EPPI, 3200 Henry Avenue, Philadelphia, PA 19129 USA.
    Affiliations
    Medical College of Pennsylvania at Eastern Pennsylvania Psychiatric Institute, Philadelphia, PA, and Norristown State Hospital, Norristown, PA, USA
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  • Cherian Verghese
    Affiliations
    Medical College of Pennsylvania at Eastern Pennsylvania Psychiatric Institute, Philadelphia, PA, and Norristown State Hospital, Norristown, PA, USA
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  • Joseph I. Tracy
    Affiliations
    Medical College of Pennsylvania at Eastern Pennsylvania Psychiatric Institute, Philadelphia, PA, and Norristown State Hospital, Norristown, PA, USA
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  • Richard C. Josiassen
    Affiliations
    Medical College of Pennsylvania at Eastern Pennsylvania Psychiatric Institute, Philadelphia, PA, and Norristown State Hospital, Norristown, PA, USA
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  • George M. Simpson
    Affiliations
    Medical College of Pennsylvania at Eastern Pennsylvania Psychiatric Institute, Philadelphia, PA, and Norristown State Hospital, Norristown, PA, USA
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      Abstract

      Polydipsia among chronic psychiatric patients is poorly understood and underdiagnosed. It may have three stages: simple polydipsia, polydipsia with water intoxication, and physical complications.
      Epidemiological surveys have used staff reports and polyuria measures to identify polydipsic patients. Water intoxication has been screened by chart review, weight, or serum sodium data. According to these surveys, polydipsia, not explained by medically induced polyuria, may be present in more than 20% of chronic inpatients. Up to 5% of chronic inpatients had episodes of water intoxication although mild cases may have been missed. Single time point surveys show that 29% of polydipsic patients had presented water intoxication.
      Methodologically limited clinical studies suggest that polydipsia with water intoxication rather than simple polydipsia may be associated with poor prognosis in schizophrenia. Epidemiological surveys found polydipsia with water intoxication to be associated with chronicity, schizophrenia, smoking, some medications, male gender, and white race. New pathophysiological models need to elucidate these findings.

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      References

        • Allon M.
        • Allen H.M.
        • Deck L.V.
        • et al.
        Role of cigarette use in hyponatremia in schizophrenic patients.
        Am J Psychiatry. 1990; 147: 1075-1077
        • Ashraf N.
        • Locksley R.
        • Arieff A.I.
        Thiazide-induced hyponatremia associated with death or neurologic damage in outpatients.
        Am J Med. 1981; 70: 1163-1168
        • Barlow E.D.
        • De Wardener H.E.
        Compulsive water drinking.
        Q J Med. 1959; 28: 235-258
        • Blum A.
        The possible role of tobacco smoking in hyponatremia of long-term psychiatric patients.
        JAMA. 1984; 252: 2864-2865
        • Blum A.
        • Tempey F.W.
        • Lynch W.J.
        Somatic findings in patients withd psychogenic polydipsia.
        J Clin Psychiatry. 1983; 44: 55-56
        • Bremner A.
        • Reagan A.
        Polydipsia and water intoxication in a mental handicap hospital.
        Br J Psychiatry. 1991; 158: 244-250
        • Cuesta M.J.
        • Juan J.A.
        • Peralta V.
        Secondary seizures from water intoxication in anorexia nervosa.
        Gen Hosp Psychiatry. 1992; 14: 212-213
        • Delva N.J.
        • Crammer J.L.
        Polydipsia in chronic psychiatric patients body weight and plasma sodium.
        Br J Psychiatry. 1988; 152: 242-245
        • Delva N.J.
        • Crammer J.L.
        • Jarzylo S.V.
        • et al.
        Osteopenia, pathological fractures, and increased urinary calcium excretion in schizophrenic patients with polydipsia.
        Biol Psychiatry. 1989; 26: 781-793
        • Emsley R.A.
        • Van de Meer H.
        • Aalbers C.
        • Taljaard J.J.F.
        Inappropriate antidiuretic state in long-term psychiatric inpatients.
        South African Med J. 1990; 77: 307-308
        • Evenson R.C.
        • Jos C.J.
        • Mallya A.R.
        Prevalence of polydipsia among public psychiatric patients.
        Psychol Rep. 1987; 60: 803-807
        • Ferrier I.W.
        Water intoxication in patients with psychiatric illness.
        Br Med J. 1985; 291: 1594-1595
        • Fraser C.L.
        • Kucharczyk J.
        • Arieff A.I.
        • et al.
        Sex differences result in increased morbidity from hyponatremia in female rats.
        Am J Physiol. 1989; 256: R880-R885
        • Gleadhill I.C.
        • Smith T.A.
        • Yium J.J.
        Hyponatremia in patients with schizophrenia.
        South Med J. 1982; 75: 426-428
        • Godleski L.S.
        • Vieweg W.V.
        • Barber J.W.
        • et al.
        Prevalence of polyuria among chronically psychotic men.
        Psychiatr Med. 1988; 6: 114-120
        • Goldman M.B.
        A rational approach to disorders of water balance in psychiatric patients.
        Hosp Comm Psychiatry. 1991; 42: 488-494
        • Goldman M.B.
        • Janecek H.M.
        Neuroleptics do not worsen hyponatremia in hyponatremic psychotics.
        Schizophr Res. 1989; 1: 1711-1715
        • Goldman M.B.
        • Luchins D.J.
        Prevention of episodic water intoxication with target weight procedure.
        Am J Psychiatry. 1987; 144: 365-366
        • Goldman M.B.
        • Luchins D.J.
        • Robertson G.L.
        Mechanisms of altered water metabolism in psychotic patients with polydipsia and hyponatremia.
        N Engl J Med. 1988; 318: 397-403
        • Hariprasad M.K.
        • Eisinger R.P.
        • Nadler I.M.
        • et al.
        Hyponatremia in psychogenic polydipsia.
        Arch Int Med. 1980; 140: 1639-1642
        • Illowsky B.P.
        • Kirch D.G.
        Polydipsia and hyponatremia in psychiatric patients.
        Am J Psychiatry. 1988; 145: 675-683
        • Jose C.J.
        • Evenson R.C.
        • Mallya A.R.
        Self-induced water intoxication: A comparison of 34 cases with matched controls.
        J Clin Psychiatry. 1986; 47: 368-370
        • Jose C.J.
        • Evenson R.C.
        Antecedents of self-induced water intoxication.
        J Nerv Ment Dis. 1980; 168: 498-500
        • Jose C.J.
        • Perez-Cruet J.
        Incidence and morbidity of self-induced water intoxication in state mental hospital patients.
        Am J Psychiatry. 1979; 136: 221-222
        • Kirch D.G.
        • Bigelow L.B.
        • Weinberger D.R.
        • et al.
        Polydipsia and chronic hyponatremia in schizophrenic inpatients.
        J Clin Psychiatry. 1985; 46: 179-181
        • Kirch D.G.
        • Elkasef A.
        • Suddath R.L.
        • et al.
        The neuroanatomy of polydipsia-hyponatremia.
        in: CME Syllabus Proceeding Summary, p. 193. American Psychiatric Association 165th Annual Meeting, Washington, DC1992 (Symposium 49C)
        • Kishimoto T.
        • Hirai M.
        • Ohsawa H.
        • et al.
        Manners of arginine vasopressin secretion in schizophrenic patients—with reference to the mechanisms of water intoxication.
        Jpn J Psychiatry Neurol. 1989; 43: 161-169
        • Koczapski A.B.
        • Ibraheem S.
        • Ashby Y.T.
        • Paredes J.
        • Jones B.D.
        • Ancill R.
        Early diagnosis of water intoxication by monitoring diurnal variations in body weight (letter).
        Am J Psychiatry. 1987; 144: 1626
        • Koczapski A.B.
        • Millson R.C.
        Individual differences in serum sodium levels in schizophrenic men with self-induced water intoxication.
        Am J Psychiatry. 1989; 146: 1614-1615
        • Koczapski A.B.
        • Ledwidge B.
        • Paredes J.
        • et al.
        Multisubstance intoxication among schizophrenic inpatients: Reply to Hyde.
        Schizophr Bull. 1990; 16: 373-375
        • Kushnir M.
        • Schattner A.
        • Ezri T.
        • Konichezky S.
        Schizophrenia and fatal self-induced water intoxication with appropriately-diluted urine.
        Am J Med Sci. 1990; 300: 385-387
        • Langgard H.
        • Smith W.O.
        Self-induced water intoxication without predisposing illness.
        N Engl J Med. 1962; 226: 378-381
        • Lawson W.B.
        • Karson C.N.
        • Bigelow L.B.
        Increased urine volume in chronic schizophrenic patients.
        Psychiatry Res. 1985; 14: 323-331
        • Lawson W.B.
        • Roy S.
        • Parent M.
        • et al.
        L. Fluid intake patterns in schizophrenia and normal controls.
        Prog Neuropsychopharmacol Biol Psychiatry. 1992; 16: 39-44
        • Lawson W.B.
        • Lyon N.
        • Karson C.N.
        Schizophrenia dementia revisited (NR 307).
        in: New Research Program and Abstracts. American Psychiatric Association, Annual Meeting, Washington, DC1992
        • Luchins D.J.
        A possible role of hippocampal dysfunction in schizophrenic symptomatology.
        Biol Psychiatry. 1990; 28: 87-91
        • Moskowitz D.W.
        Functional obstructive uropathy: A significant factor in the hyponatremia of psychogenic polydipsia?.
        J Urol. 1992; 147: 1611-1613
        • Okura M.
        • Morii S.
        Polydipsia, polyuria and water intoxication observed in psychiatric impatients.
        Tokushima J Exp Med. 1986; 33: 1-5
        • Peh L.H.
        • Devan G.S.
        • Eu P.W.
        Water intoxication in psychiatric patients in Singapore.
        Singapore Med J. 1990; 31: 238-241
        • Pfister H.O.
        Disturbances of the autonomic nervous system in schizophrenia and their relations to the insulin, cardiazol and sleep treatments.
        Am J Psychiatry. 1934; 94 (May supplementum): 109-118
        • Raskind M.A.
        • Courtney N.
        • Murburg M.M.
        • et al.
        Antipsychotic drugs and plasma vasopressin in normals and acute schizophrenic patients.
        Biol Psychiatry. 1987; 22: 453-462
        • Riggs A.T.
        • Dysken M.W.
        • Kim S.W.
        • Opsahl J.A.
        A review of disorders of water homeostasis in psychiatric patients.
        Psychosomatics. 1991; 32: 133-148
        • Ripley T.L.
        • Millson R.C.
        • Koczapski A.B.
        Self-induced water intoxication and alcohol abuse.
        Am J Psychiatry. 1989; 146: 102-103
        • Rosenbaum J.F.
        • Rothman J.S.
        • Murray G.B.
        Psychosis and water intoxication.
        J Clin Psychiatry. 1979; 40: 287-291
        • Rowe J.W.
        • Kilgore A.
        • Robertson G.L.
        Evidence in man that cigarette smoking induces vasopressin release via an airway-specific mechanism.
        J Clin End Metab. 1990; 51: 170-171
        • Schnur D.B.
        • Wirkowski E.
        • Muklargee S.
        • et al.
        Cognition, water balance and schizophrenia.
        in: CME Syllabus Proceeding Summary, American Psychiatric Assoc 165th Annual Meeting, Washington, DC1992 (Symposium 49E)
        • Shah P.J.
        • Greenberg W.M.
        Polydipsia with hyponatremia in a state hospital population.
        Hosp Comm Psychiatry. 1992; 43: 509-511
        • Shen W.W.
        • Sato L.S.
        Hypothalamic dopamine receptor supersensitivity.
        Psychiatry J Univ Ottawa. 1983; 8: 54-158
        • Sleeper F.H.
        Investigation of polyuria in schizophrenia.
        Am J Psychiatry. 1935; 91: 1019-1031
        • Sleeper F.H.
        • Jellinek E.M.
        A comparative physiologic psychologic and psychiatric study of polyuric and nonpolyuric schizophrenic patients.
        J Nerv Ment Dis. 1936; 83: 557-563
        • Suzuki M.
        • Takeuchi O.
        • Mori I.
        • et al.
        Syndrome of inappropriate secretion of antidiuretic hormone associated with schizophrenia.
        Biol Psychiatry. 1992; 31: 1057-1061
        • Verghese C.
        • de Leon J.
        • Simpson G.M.
        Neuroendocrine factors influencing polydipsia in psychiatric patients: an hypothesis.
        Neuropsychopharmacology. 1993; 9: 157-166
        • Vieweg W.V.R.
        • Rowe W.T.
        • David J.J.
        • et al.
        Evaluation of patients with self-induced water intoxication and schizophrenic disorders (SIWIS).
        J Nerv Ment Dis. 1984; 172: 552-555
        • Vieweg W.V.R.
        • David J.J.
        • Wampler G.J.
        • et al.
        Death from self-induced water-intoxication among patients with schizophrenic disorders.
        J Nerv Ment Dis. 1985; 173: 161-165
        • Vieweg W.V.R.
        • David J.J.
        • Rowe W.T.
        • et al.
        Diurnal variation of urinary excretion for patients with psychosis, intermittent hyponatremia, and polydipsia (PIP syndrome).
        Biol Psychiatry. 1986; 21: 1031-1042
        • Vieweg W.V.R.
        • David J.J.
        • Glick J.L.
        • et al.
        Polyuria among patients with psychosis.
        Schizophr Bull. 1986; 12: 739-743
        • Vieweg W.V.R.
        • Hundley P.L.
        • Godleski L.S.
        • et al.
        Diurnal weight gain as a predictor of serum sodium concentration in patients with psychosis, intermittent hyponatremia, and polydipsia (PIP syndrome).
        Psychiatr Res. 1987; 26: 305-312
        • Vieweg W.V.R.
        • Godleski L.S.
        • Graham P.
        • et al.
        Abnormal diurnal weight gain among long-term patients with schizophrenic disorders.
        Schizophr Res. 1988; 1: 67-71
        • Vieweg W.V.R.
        • Weiss N.M.
        • David J.J.
        • et al.
        Treatment of psychosis intermittent hyponatremia and polydipsia (PIP syndrome) with lithium and phentoyin.
        Biol Psychiatry. 1988; 23: 25-30
        • Vieweg W.V.R.
        • Godleski L.S.
        • Hundley P.L.
        • et al.
        Antipsychotic drugs, lithium, carbamazepine, and abnormal diurnal weight gain in psychosis.
        Neuropsychopharmacol. 1989; 2: 39-43
        • Vieweg W.V.R.
        • Harrington D.P.
        • Leadbetter R.A.
        • et al.
        Prediction of serum sodium based on diurnal weight gain among schizophrenics subject to water intoxication'.
        Psychiatry & Psychobiology. 1990; 5: 265-267
        • Vieweg W.V.R.
        • Pandurangi A.K.
        • Pelonero A.L.
        Estimating daily urine volume in chronic psychosis.
        Schizophr Res. 1992; 8: 68-92
        • Zubenko G.S.
        Water homeostasis in psychiatric patients.
        Biol Psychiatry. 1987; 22: 121-125