CITATION: Emsley, R. A. & Taljaard, J. J. F. 1988. Self-induced water intoxication : a case report. South African Medical Journal, 74:80-81.The original publication is available at http://www.samj.org.zaA 19-year-old female schizophrenic with self-induced water intoxication is described. Factors of pathogenic significance included primary polydipsia and non-maximal urinary diluting capacity.Publisher’s versio

Emsley, R. A.

Taljaard, J. J. F.

Stellenbosch University SUNScholar Repository

80 SAMJ VOL 74 16 JUL 1988the clinical complications. How cholestanol interferes with cellfunctioning is not fully understood.. Treating CTX patients with chenodeoxycholic acid, a bileacid, restores the bile acid pool, which in turn decreases thesynthesis of bile-acid precursors including cholestanol. Berginerer al. 6 have shown that patients on long-term treatment withchenodeoxycholic acid display improvement in dementia andother neurological signs.This is the first southern African black patient reportedwith this condition. The gene for CTX is therefore found insouthern Africa in both the black and white population groups.Patients presenting with xanthomas and a normal serumcholesterol level should be investigated for CTX since this is apotentially reversible condition which, if left untreated, mayresult in neurological deficits.REFERENCESI. Salen G, Shefer S, Berginer VM. Familial diseases with storage of sterolsother than cholesterol: cerebrotendinous xanthomatosis and sitosterolemiawith xanthomatosis. In: Stanbury JB, Wyngaarden JB, Fredrickson DS,Goldstein JL, Brown MS, eds. The Mecaholic Basis of Inherited Diseases. 5thed. New York: McGraw-Hill, 1983: 713-730.2. Grundy SM. Cerebrotendinous xanthomatosis. N Engl] Med 1984; 31I:1694-1695.3. Truswell AS, Pfister PI. Cerebrotendinous xanthomatosis. Br Med] 1972;I: 353-354.4. Berginer VM, Abeliovich D. Genetics of cerebrotendinous xanthomatosis:an autosomal recessive trait with high gene frequency in Sephardim ofMoroccan origin. Am] Med Genec 1981; 10: 151-157.5. Oftebro H, Bjorkhem I, Sksede S, Schreiner A, Pederson JI. Cerebro-tendinous xanthomatosis: a defect in mitochondrial 26-hydroxylation requiredfor normal biosynthesis of cholic acid.] Clin ITWesc 1980; 65: 1418-1430.6. Berginer VM, Salen G, Shefer S. Long-term treatment of cerebrotendinousxanthomatosis with chenodeoxycholic acid. N Engl J Med 1984; 31I: 1649-1652.Self-induced water intoxication.A case reportR. A. EMSLEY, J. J. F. TALJAARDSummaryA 19-year-old female schizophrenic with self-induced waterintoxication is described. Factors of pathogenic significanceincluded primary polydipsia and non-maximal urinary dilutingcapacity.S AIr Med J 1988; 74: 80-81.. Self-induced water intoxication is a condition found almostexclusively in patients with psychiatric disorders, especially ofthe schizophrenic type. I The two most important pathogenicfactors are primary polydipsia (also referred to as compulsivewater drinking or psychogenic polydipsia) and an inappropriateantidiuretic state. 2 Primary polydipsia alone does not usuallylead to water intoxication because of the tremendous excretorycapacity of the kidneys when vasopressin secretion is adequatelysuppressed. However, in the syndrome of inappropriate secre-tion of antidiuretic hormone (SIADH) maximum water diuresisis prevented and water intoxication may ensue. 3Case reportA 19-year-old coloured female was admitted to the PsychiatryUnit, Tygerberg Hospital, with a sudden onset of agitation,MRC Unit for the Neurochemistry of Mental Diseases,Department of Psychiatry, University of Stellenbosch andTygerberg Hospital, Parowvallei, CPR. A. EMSLEY, M.B. CH. B., M.MED. (PSYCH.)J. J. F. TALJAARD, ,1.1.0.Accepted 10 Dec 1987.verbal hallucinations, paranoid delusions and suicidal behaviour.She had been discharged from a psychiatric hospital 2 weekspreviously, where she was diagnosed as suffering from schizo-phrenia and was treated with trifluoperazine 30 mg/d. Whenexamined she was apathetic and non-responsive. Physicalexamination revealed nothing of note. The blood pressure was120170 mmHg, pulse 60/min and temperature normal. Therewere no localising neurological signs.After admission to the ward she again became agitated andconfused. She was noted to be drinking water almost con-tinuously, was repeatedly seen going to the toilet and vomitedonce. Laboratory investigations performed the day after ad-mission revealed the following serum values: sodium 124mmol/l, potassium 3,7 mmol/l, chloride 92 mmol/l, urea 2,1mmol/l and creatinine 65 j1mol/1. Osmolality was 254 mmol/kgH20 and glucose 4,7 mmol/l. Concomitant urine osmolalitywas 151 mmol/kg H 20. Haematological tests were normal, aswere liver function tests, chest radiography, ECG, electro-encephalogram and computed tomography of the head.The trifluoperazine was discontinued and fluid intakerestricted. Within 4 days the patient's psychiatric state hadreturned to normal. Serum sodium value was 137 mmol/l andosmolality 275 mmol/kg H 20. A standard water load test4performed at the time revealed no defect of water excretorycapacity. Three months later there had been no recurrence ofthe polydipsia and her' psychiatric state had remained normal.DiscussionDisturbances in water balance in psychiatric patients havebeen recognised for over 50 years. Sleeper and Jellinek5observed that many schizophrenics exhibited polyuria - andthat this ceased when fluid intake was restricted. Subsequentlynumerous cases of such patients developing water intoxicationhave been reported (see Vieweg et al. 6). In the present case thepresence of profound hyponatraemia together with polydipsia,vomiting and confusion accord with a diagnosis of waterintoxication.Most of the patients in published reports of water intoxica-tion displayed primary polydipsia (i.e. abnormal drinking beha-viour caused by psychiatric or neurophysiological mechanismsin the absence of need) as well as impairment of urinaryexcretory capacity. In the present case, the urinary osmolalityof 151 mmol/kg HzO in the face of serum hypotonicity is lessthan maximally dilute, and indicates a mild impairment ofexcretory capacity. The most likely cause of this is SIADH.3The possibility that the clinical triad of psychosis, polydipsiaand SIADH could result from a common underlying cerebraldisorder has been suggested by Raskind et al. 7 These authorspropose that a disturbance in limbic system function, possiblyinvolving a hyperdopaminergic state, could explain the co-existence of psychosis, polydipsia and SIADH. As supportiveevidence they cite experimental and clinical studies implicatingthe limbic-hypothalamic dopamine system of the brain in.psychotic illness8 and in central thirst and vasopressin secretorymechanisms.9The role of medication in the development of water intoxica-tion in our patient and other such cases is uncertain. Thus, thefact that the patient's symptoms improved after stopping thetrifluoperazine accords with previous reports of neuroleptic-induced SIADH (see Jose et al. 10). On the other hand, neuro-leptic drugs have been shown not to have a pervasive stimula-tory effect on vasopressin secretion, I I and elevated plasmavasopressin values have been reported in medication-freepsychotic patients. IZ Other drugs (not present in this case)associated with the development of SIADH in psychiatricpatients include tobacco smoking,13 carbamazepine I4 andthiazide diuretics. 15Whatever the mechanisms involved, heightened physicianawareness of the condition is required, considering the implica-tions. The prevalence of water intoxication in a state mentalhospital has been estimated as. 7%,16 <md nearly a fIfth ofSAMT VOL. 74 16JUL 1988 81deaths in schizophrenics aged under 50 years were anributableto self-induced water intoxication. 17This work was supported by the South African Medical ResearchCouncil.REFERENCESI. Jos cJ, Evenson RC, MalIya AR. Self-induced water intoxication: a com-parison of 34 cases with matched controls. ] Clin Psychiatry 1986; 47:368-370.2. RobertSon GL. Psychogenic polydipsia and inappropriate antidiuresis. ArchIntern Med 1980; 140: 1574-1575.3. Bamer FC, Schw3rtZ WB. The syndrome of inappropriate secretion ofantidiuretic hormone. Am] Med 1967; 42: 790-805.4. Robertson GL. Diseases of the posterior pituitary. In: Felig P, Baxter JD,Broadus AE, Frohman LA, eds. Endocrinology and Mecabolism. New York:McGraw-Hill, 1981: 251-277.5. Sleeper FH, Jellinek EM. A comparative physiologic, psychologic andpsychiatric study of pol)'Uric and non-polyuric schizophrenic patients. JNeru Ment Dis 1936; 83: 557-563.6. Vieweg WVR, David 11, Rowe WT et al. Psychogenic polydipsia and watetintoxication - concepts that have failed. Bioi Psychiatry 1985; 20: 1308-1320.7. Raskind MA, Orenstein H, Christopher TG. Acute psychosis, increasedwater ingestion and inappropriate antidiuretic hormone secretion. Am JPsychiatry 1975; 132: 907-910.8. Doty RW. Limbic sysrem. In: Freedman AM, Kaplan HI, eds. Comprehen-sive Textbook of Psychiatry. Baltimore: Williams & Wilkins, 1967: 125-143.9. Mogenson GJ. Hypothalamic limbic mechanisms in the control of watetintake. In: Epstein AN, Kisseleff HR, Stellar E, eds. Neuropsychology ofThirst. New York: Halsread Press, 1973: 19-42.10. Jose CJ, Mehta S, Perez-Cruet J. The syndrome of inappropriate secretionof antidiureric hormone (SIADH). Can] Psychiatry 1979; 24: 225-231.11. Raskind M, Courtney N, Backus F, Weiuman R. Antipsychoric drugs andplasma vasopressin. Scientific Proceedings of the 135th Annual Meeting of theAmerican Psychiatric Association. Washingron, DC: APA, 1982.12. Raskind MA, Weiuman RE, Orenstein H, Fisher DA, Courrney N. Isantidiuretic hormone elevated in psychosis? A pilot study. Bioi Psychiatry1978; 13: 385-390.13. Blum A. The possible role of tobacco cigarette smoking in hyponarremia oflong-rerm psychiatric patients. ]AMA 1984; 252: 2864-2865.14. Gold PW, RobertSon GL, BalIenger JC et al. Carbamazepine diminishes thesensitivity of the plasma arginine vasopressin response to osmotic stimulation.] Clin Endocrinol Mecab 1983; 57: 952-957.15. Emsley RA, Gledhill RF. Thiazides, compulsive water drinking and hypona-rremic encephalopathy.] Neurol Neurosurg Psychiatry 1984; 47: 886-887.16. Jose Cl, Perez-Cruet J. Incidence and morbidity of self-induced waterintoxication in state mental hospiral patients. Am] Psychiatry 1979; 136:221-222.17. Vieweg WVR, David 11, Rowe WT, Wampler GJ, Burns WJ, SpradlinWW. Death from self-induced water intoxication among patients withschizophrenic disorders.] Neru Ment Dis 1985; 173: 161-165.

Self-induced water intoxication : a case report

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Self-induced water intoxication : a case report

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