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Psychogenic Polydipsia – the Forgotten Syndrome Literature Review and Illustrative Case Series

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Psychogenic Polydipsia – the Forgotten Syndrome Literature Review and Illustrative Case Series Psychogenic Polydipsia – the Forgotten Syndrome Literature Review and Illustrative Case Series Ewelina De Leon, Research Assistant, St Matthew’s Healthcare, Northampton Prof Graeme Yorston, Consultant Forensic Neuropsychiatrist, University of Chester BACKGROUND RESULTS CASE SERIES Ten men and one woman with Polydipsia , meaning insatiable thirst, was first used in English in 1661. The compulsive drinking of fluids was first reported in the 19th century, In some psychogenic polydipsia were and the term dipsomania was applied primarily and later exclusively to patients the identified at St Matthews Healthcare. interventions were For detail description of the case people who drank alcohol. After that: ineffective due to In 1923 - Rowntree et al. studied fluid dysregulation in patients with aggressive series please scan the QR code below. psychiatric disorders. behaviour, threats and violence. But others In 1935 - Sleeper noted consumption of large quantities of liquids in reduced overall psychiatric patients. consumption In 1938 – Barahal reported the first case of water intoxication of fluids Some patients (over-hydration). were admitted to Patients displayed hospital to correct Subsequently, research into psychogenic polydipsia, compulsive water challenging behaviour: hyponatraemia, drinking, and self-induced water intoxication took off, being frequently violence, aggression, however on return reported in the psychiatric literature. However, a recent MEDLINE search hostility, verbal abuses continued with the has shown a waning of interest in the topic, possibly as a result of and anger if their excessive de-institutionalisation. demands for a drink drinking were not met immediately Figure 1. The graph shows a waning of interest in the topic in recent years One patient admitted addiction to cola, another said she drank apple 83% of our juice because patients preferred it tasted cola. Other drinks included milk, like alcohol Psychogenic polydipsia is defined as the excessive energy drinks, fruit consumption of fluids (>3L/day) without physiological stimuli juices, tea, to drink. Estimates of the prevalence in psychiatric patients coffee and range between 6-20% (Dundas et al., 2007; Verghese et al., 1996). water It is more common in institutionalised patients with severe long-term psychosis but it is also reported in patients who Alzheimer’s Paranoid and mixed live in the community (Illosky & Kirch, 1988; Fluid charts Schizophrenia Dementia Regular Williams et al., 2010, 2011). It can also occur as a and drinking blood tests to post-operative complication and after traumatic brain structure monitor urea injury in people with no history of mental illness. implemented and ADHD into a daily electrolytes Excessive water intake may lead to dysregulation of routine the hypothalamic-pituitary axis and electrolyte imbalance with hyponatraemia Schizoaffective (sodium <135mmol/L) and water intoxication Disorder (Perestrelo et al., 2016). The clinical features of these two conditions include worsening of psychotic symptoms, Locking delirium, confusion, agitation, nausea, Switching access to vomiting, headaches, seizures, coma and Misuse of off the water bedroom to death. Furthermore, low levels of sodium may drugs and supply to a prevent drinking mimic symptoms of psychosis including behavioural alcohol bedroom from sinks and lavatories changes, irritability, impulsivity and hyperactivity (Aguiar et al., 2015; Gill et al. 2015). Learning Even though we have over 100 years of knowledge Autistic Disability of this syndrome, its pathophysiology is still poorly Spectrum REFERENCES understood. Disturbance of the thirst mechanism, Aguiar, D.T., Monteiro, C. & Coutinho, P. 2015, "Recurrent rhabdomyolysis secondary to hypo- natremia in a patient with primary psychogenic poly- hyperdopaminergic activities, defects in dipsia", Revista Brasileira de terapia intensiva, vol. LITERATURE REVIEW 27, no. 1, pp. 77-81. Ahmed, S.E. & Khan, A.H. 2017, "Acetazolamide: osmoregulation and hypersensitivity to vasopressin Treatment of Psychogenic Polydipsia", Curēus (Palo Alto, CA), vol. 9, no. 8, pp. e1553. Barahal, H.S. (1938). Water intoxication in a mental are just a few of the theories that have been suggested case. The Psychiatric Quarterly, 12(4), pp.767–771. Psychogenic polydipsia has been mostly described in patients with schizophrenia, but it can also occur in Bhatia, M.S., Goyal, A., Saha, R. & Doval, N. 2017, (Bhatia et al., 2017; llosky & Kirch, 1988). "Psychogenic Polydipsia- management challeng- es", Shanghai Jingshen Yixue, vol. 29, no. 3, pp. 180- people with schizoaffective disorder, bipolar disorder, obsessive-compulsive disorder, anorexia nervosa, 183 de Leon, J. 2003, "Polydipsia: A study in a long-term depression, anxiety, autistic spectrum disorders, learning disability and dementia (de Leon et al., 2003; Ko et al., psychiatric unit", European Archives of Psychiatry Compulsive water drinking is a complex condition and and Clinical Neurosciences, vol. 253, no. 1, pp. 37-39. 2015). de Leon, J., Verghese, C., Tracy, J.I., Josiassen, R.C. & challenging to recognise as it needs to be differentiated Simpson, G.M. 1994, "Polydipsia and water intoxica- tion in psychiatric patients: a review of the epidemi- ological literature", Biological psychiatry (1969), vol. from disorders with similar presentations like diabetes 35, no. 6, pp. 408. Dundas, B., Harris, M. & Narasimhan, M. 2007, Hyponatraemia and water intoxication can lead to cerebral oedema, central pontine myelinolysis and "Psychogenic polydipsia review: Etiology, differential, insipidus. Consequently, clinicians face real difficulties and treatment", Current Psychiatry Reports, vol. 9, extrapontine myelinolysis. It can also cause rhabdomyolysis which in turn can damage the kidneys. no. 3, pp. 236-241. Fleming, G. W. T. H 1936, "A Comparative Physiolog- in the assessment and monitoring of patients such that, ic, Psychologic and Psychiatric Study of Polyuric and Non-polyuric Schizophrenic Patients. (Journ. Nerv. and Ment. Dis., vol. lxxxiii, p. 557, May, 1936.) Sleep- even though this syndrome is common and is known to er, F. H., and Jellinek, E. M", Journal of mental sci- Hyponatremia caused by excessive drinking can develop in about 20% of schizophrenic patients ence, vol. 82, no. 339, pp. 456-457. lead to permanent brain damage and death in some cas- Gill, M. & McCauley, M. 2015, "Psychogenic Polydip- sia: The Result, or Cause of, Deteriorating Psychotic (de Leon et al., 1994; Goldman et al., 1997). Symptoms? A Case Report of the Consequences of es, it often goes unrecognised or is poorly managed. Water Intoxication", Case reports in psychiatry, vol. 2015, pp. 846459-3. Goldman, M.B., Robertson, G.L., Luchins, D.J., Hede- Animal studies showed that water intoxication increases the permeability of the blood-brain barrier. It can cause ker, D. & Pandey, G.N. 1997, "Psychotic exacerba- tions and enhanced vasopressin secretion in schizo- phrenic patients with hyponatremia and polydipsia", cell damage, myelin impairments and structural changes in the central nervous system (Kozler et al., 2016). Archives of general psychiatry, vol. 54, no. 5, pp. 443. Illosky, B. and Kirch, D. (1988). Polydipsia and hypo- natremia in psychiatric patients. American Journal of Psychiatry, 145(6), pp.675–683. OBJECTIVES Ko, A. R. et al. (2015) ‘Hypotonic hyponatremia by primary polydipsia caused brain death in a 10-year- Long-term psychiatric patients are at higher risk of water intoxication; 80% of old boy’, Annals of pediatric endocrinology & metab- olism, 20(3), pp. 166–169. doi: 10.6065/ patients with polydipsia and water intoxication have schizophrenia. apem.2015.20.3.166. Kozler, P., Sobek, O. & Pokorny, J. 2016, "Biochemical manifestations of the nervous tissue Predisposing factors include smoking, drugs and alcohol misuse, family history degradation after the blood-brain barrier opening or water intoxication in rats", Neuro-endocrinology To present letters, vol. 37, no. 2, pp. 114. and certain medication (de Leon et al., 1994, 2003; Shinkai et al., 2003). Perestrelo, J. & Teixeira, B. 2016, "Psychogenic poly- a literature review dipsia and hyponatremia – A side effect of psychosis: a review with a case report", Jornal Brasileiro de To increase psiquiatria, vol. 65, no. 3, pp. 300-303. and case series of METHOD Reynolds S A, Schmid MW, Broome ME. Polydipsia There are no evidence-based treatment guidelines, but the following screening tool. Arch Psychiatr Nurs.2004;18(2):49- awareness of psychogenic 59. Rowntree, L.G. (1923). Water Intoxication. Archives psychogenic management strategies have been proposed: water restriction, monitoring of of Internal Medicine, 32(2), p.157. polydipsia Literature review: A comprehensive literature Shinkai, T., Ohmori, O., Hori, H. & Nakamura, J. 2003, "Genetic approaches to polydipsia in schizophrenia: polydipsia and its diurnal weight gain and urine specific gravity, weekly blood tests and review A preliminary report of a family study and an associ- review was conducted following a search of the ation study of an angiotensin‐converting enzyme gene polymorphism", American Journal of Medical of symptoms and behavioural changes. Medication including acetazolamide, Genetics Part B: Neuropsychiatric Genetics, vol. complications MEDLINE, CINAHL Plus, APA PsycArticles, APA 119B, no. 1, pp. 7-12. enalapril and irbesartan has also been proposed (Ahmed et al., 2017; Verghese, C., de Leon, J. & Josiassen, R.C. 1996, "Problems and progress in the diagnosis and treat- PsycBooks, APA
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