Access to this full-text is provided by Wiley.
Content available from Case Reports in Psychiatry
This content is subject to copyright. Terms and conditions apply.
Case Report
Psychogenic Polydipsia Complicated to Hyponatremia Induced
Seizure in Schizophrenia: A Case Report from Nepal
Pawan Sharma ,1 Bigya Shah,1 Modnath Sangroula,2 and Richan Jirel2
1Department of Psychiatry, Patan Academy of Health Sciences, School of Medicine, Lalitur, Nepal
2Medical Officer, Arogin Health Care and Research Centre, Kathmandu, Nepal
Correspondence should be addressed to Pawan Sharma; pawan60@gmail.com
Received 29 May 2019; Accepted 9 October 2019; Published 16 November 2019
Academic Editor: Michael Kluge
Copyright © 2019 Pawan Sharma et al. is is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Psychogenic polydipsia is one of the common cooccurrences with Schizophrenia and if not addressed can lead to fatal consequences.
ere are some evidences for pharmacological management of this condition but nonpharmacological management starting from
psycho-education to behavioural modication therapy involving family members can be a very eective strategy. We report a case
from Nepal where psychogenic polydipsia was complicated to hyponatremia and lead to seizure episodes. We emphasize on asking
a routine question about polydipsia in every patient of Schizophrenia in clinics.
1. Introduction
Polydipsia conventionally dened as the excessive intake of
liquids more than 3 liters per day is poorly understood and
underdiagnosed among chronic psychiatric patients [1]. e
researchers have identied polydipsia to be associated with
schizophrenia as early as 1923 [2]. It is estimated that about
20% of patients with schizophrenia exhibit primary polydipsia
and about 20% of these patients experience life-threatening
hyponatremia [1]. Retrospective review of records has shown
self-induced water intoxication as a cause of death in consid-
erable number of patients with schizophrenia [3]. e mech-
anism of altered water metabolism is poorly understood in
these cases [4]. Evidence show that the prevalence of water
intoxication among polydipsic patients of Asian origin with
schizophrenia to be low compared to Western studies [5]. We
report a case of schizophrenia who presented to our tertiary
hospital setting with polydipsia, hyponatremia and seizure
episodes and was managed conservatively.
2. Case Presentation
A 39 years old male presented to the emergency department
with a history of two episodes of seizure with altered con-
sciousness. He was admitted in ICU with supportive
management and relevant investigations were done. Detailed
history taken from his father revealed he had a chronic psy-
chiatric illness for last 20 years characterized by aggressive
behaviour, muttering to self, fearfulness and decreased sleep.
He also had disorganized behaviour in the form of not bathing
and washing, drinking dirty water stored for the purpose of
toilet use and collecting garbage without apparent reason. He
had marked apathy and blunting of emotional responses that
resulted in social withdrawal and lowering of social perfor-
mance. He also had a history of irrelevant talk when trying to
hold a conversation. Considering these symptoms, a DSM 5
diagnosis of Schizophrenia was made. Treatment history
revealed he was maintaining well on tablet Risperidone 2 mg/
day for last three years.
Apart from this, his father also gave a history of increased
intake of water for last two years. He would drink around 5-6
liters of water per day that had increased to around 9-10 liters
per day in the last few weeks. When asked, he wouldn’t justify
the amount of water intake but simply answered that he was
thirsty and had an urge to drink water. He also had polyuria.
On the day of presentation in our tertiary care center, he had
two episodes of generalized tonic-clonic seizure. His investi-
gation revealed values as shown in Table 1.
As per the laboratory reports he appears to meet the cri-
teria for Syndrome of Inappropriate Antidiuretic Hormone
Secretion (SIADH) [6]. However considering the presence of
Hindawi
Case Reports in Psychiatry
Volume 2019, Article ID 6021316, 3 pages
https://doi.org/10.1155/2019/6021316
Case Reports in Psychiatry2
polyuria and no other secondary causes, a provisional diag-
nosis of psychogenic polydipsia with hyponatremia induced
seizure was made and the dierential of SIADH was consid-
ered. Hyponatremia was corrected over two days. Restriction
of water intake was done at the hospital. He was continued on
the same dose of Risperidone. Family members and patient
were psycho-educated about eects of increased water intake
and the need to restrict the same. Behavioral therapy for com-
pulsive water drinking was started with the patient. e father
was given a role of a co-therapist. e patient was advised to
keep a log diary of intake and output of water. He was advised
to decrease his water intake by observing the log. Aer dis-
charge in a span of two months, two follow-up visits were
made. e patient showed remarkable improvement in his
water drinking, it reduced from 10 liters approx. to 5 liters/
day as seen by input/output charting made by the patient and
supervised by his father. e patient was maintaining well in
one year follow up.
3. Discussion
Psychogenic polydipsia though commonly found with patients
of schizophrenia can be a potentially fatal condition. ere
have been reports of life threatening conditions such as sei-
zure, rhabdomyolysis, aspiration pneumonia, and crural com-
partment syndrome associated with psychogenic polydipsia
[7–9]. ere are also reports of death secondary to self-in-
duced water intoxication in patients with schizophrenia [10].
e present case is an example which shows seizure as a com-
plication of hyponatremia secondary to water intoxication
caused by psychogenic polydipsia in a patient with diagnosed
schizophrenia. It is a challenge to diagnose and manage the
condition as patients themselves do not reveal and deny [11].
ere have been various methods described in literature to
treat psychogenic polydipsia. Use of medications such as
demeclocycline, propranolol, captopril, and naloxone has
shown inconsistent results [12]. Similarly, atypical antipsy-
chotics such as risperidone and quetiapine have mixed results
[11–13]. ere is fair amount of evidence suggesting that clo-
zapine is eective in reducing water intake [14], and that vas-
opressin type 2 antagonists which are primarily used to treat
heart failure are very eective in rapidly reversing and pre-
venting further cases of water intoxication [15].
Apart from pharmacological treatment, the behavioural
modication has been widely used and consists of the water
restriction program [11, 12]. Measures such as restriction of
water intake with the help of family member and daily mon-
itoring of the input, output, and electrolytes corrected this
condition in our case. Such simple and inexpensive manage-
ment by psycho-educating and involving family members as
co-therapist is benecial in lower resource settings where there
are limited stas. Furthermore, psychogenic polydipsia, like
schizophrenia, has a relapsing course [12]. erefore, non-
pharmacological measures and using family members into the
treatment may have potential benets for the long-term man-
agement. Our case imparts need to routinely assess water
intake in patients with chronic illness such as schizophrenia
so as not to miss psychogenic polydipsia. Since this has life
threatening consequences, the case also highlights importance
to its prompt diagnosis and management with water restric-
tion involving family members. is has been among the very
few reported cases from Nepal.
Conflicts of Interest
e authors declare that they have no conicts of interests.
References
[1] J. de Leon, C. Verghese, J. I. Tracy, R. C. Josiassen, and
G. M. Simpson, “Polydipsia and water intoxication in psychiatric
patients: a review of the epidemiological literature,” Biological
Psychiatry, vol. 35, no. 6, pp. 408–419, 1994.
[2] C. Verghese, J. de Leon, and R. C. Josiassen, “Problems and
progress in the diagnosis and treatment of polydipsia and
hyponatremia,” Schizophrenia Bulletin, vol. 22, no. 3, pp. 455–
464, 1996.
[3] W. V. Vieweg, J. J. David, W. T. Rowe, G. J. Wampler,
W. J. Burns, and W. W. Spradlin, “Death from self-induced water
intoxication among patients with schizophrenic disorders,” e
Journal of Nervous and Mental Disease, vol. 173, no. 3, pp.161–
165, 1985.
[4] M. B. Goldman, D. J. Luchins, and G. L. Robertson,
“Mechanisms of altered water metabolism in psychotic patients
with polydipsia and hyponatremia,” New England Journal of
Medicine, vol. 318, no. 7, pp. 397–403, 1988.
[5] S. A. Chong, L. L. Tan, M. C. Wong, S. C. Woo, C. H. Tan, and
L. L. Ng, “Disordered water homeostasis in asian patients with
schizophrenia,” Australian & New Zealand Journal of Psychiatry,
vol. 31, no. 6, pp. 869–873, 1997.
[6] M. J. Hannon and C. J. ompson, “e syndrome of
inappropriate antidiuretic hormone: prevalence, causes and
T 1:Summary of investigations done.
WNL: Within Normal Limits.
Investigations Results References
Complete hemogram WNL -
Serum Na+100 mEq/L 135−145 mEq/L
Serum K+3.9 mEq/L 3.5−5.1 mEq/L
Serum urea 24 mg/dL 15−45 mg/dL
Serum creatinine 1.0 mg/dL 0.8−1.3 mg/dL
Urine osmolality 109.2 mmol/kg 300−900 mmol/kg
Serum osmolality 145 mmol/kg 275−295 mmol/kg
Urine Na+46 mmol/L <20 mmol/L
yroid function test WNL
Blood sugar
Fasting 72 mg/dL <100 mg/dL
Post prandial 120 mg/dL <140 mg/dL
Serum Cortisol 29.46 mcg/dL 43−22.4 mcg/dL
Ultrasonography whole
abdomen WNL -
Echocardiography WNL -
CT scan head WNL -
MRI brain WNL -
3Case Reports in Psychiatry
consequences,” European Journal of Endocrinology, vol. 162,
no. 1, pp. S5–S12, 2010.
[7] L. Maiocchi and E. Bernardi, “Acute anterior compartment
syndrome associated with psychogenic polydipsia,” Australas
Psychiatry, vol. 20, no. 2, pp. 159–161, 2012.
[8] T. K. F. Gaigalat, F. T. Bopp, and M. Zinkler, “Fatal aspiration
following polydipsia in schizophrenia,” Psychiatrische Praxis,
vol. 38, no. 7, pp. 352–354, 2011.
[9] A. Ulstrup, R. Ugleholdt, and J. V. Rasmussen, “Fulminant crural
compartment syndrome preceded by psychogenic polydipsia,”
BMJ Case Reports, vol. 2015, Article ID bcr2014208603, 2015.
[10] G. Loas and E. Mercier-Guidez, “Fatal self-induced water
intoxication among schizophrenic inpatients,” European
Psychiatry, vol. 17, no. 6, pp. 307–310
[11] N. Rao, G. Venkatasubramanian, V. Korpade, R. Behere,
S. Varambally, and B. Gangadhar, “Risperidone treatment for
polydipsia and hyponatremia in schizophrenia: a case report,”
Turk Journal of Psychiatry, vol. 22, no. 2, pp. 123–125, 2011.
[12] B. Dundas, M. Harris, and M. Narasimhan, “Psychogenic
polydipsia review: etiology, dierential, and treatment,” Current
Psychiatry Reports, vol. 9, no. 3, pp. 236–241, 2007.
[13] G. Bersani, L. Pesaresi, V. Orlandi, S. Gherardelli, and
P. Pancheri, “Atypical antipsychotics and polydipsia: a cause
or a treatment?” Human Psychopharmacology: Clinical and
Experimental, vol. 22, no. 2, pp. 103–107, 2007.
[14] S. Kirino, M. Sakuma, F. Misawa et al., “Relationship between
polydipsia and antipsychotics: a systematic review of clinical
studies and case reports,” Progress in Neuro-Psychopharmacology
and Biological Psychiatry, vol. 28, p. 109756, 2019.
[15] S. B. Bhardwaj, F. B. Motiwala, M. Morais, and S. B. Lippmann,
“Vaptans for hyponatremia induced by psychogenic polydipsia,”
e Primary Care Companion for CNS Disorders, vol. 15, no.1,
2013.
Available via license: CC BY
Content may be subject to copyright.
Content uploaded by Pawan Sharma
Author content
All content in this area was uploaded by Pawan Sharma on Nov 17, 2019
Content may be subject to copyright.
