Self-Induced Water Intoxication Treated with

Risperidone
Richard C Millson, MD1, Craig E Emes, MD2, William G Glackman, PhD3

Objective: To determine whether or not risperidone is efficacious in treating self-induced water intoxication in
patients with chronic schizophrenia.
Method: We carried out a prospective 11-month open-label study using risperidone to treat 8 men with chronic
schizophrenia and self-induced water intoxication.
Results: The 8 men were not able to reduce their fluid consumption compared with their baseline intake.
Risperidone, however, significantly decreased the Brief Psychiatric Rating Scale (BPRS) scores of this very
chronic group.
Conclusions: Although risperidone decreased schizophrenic symptoms, it did not have significant efficacy in
treating self-induced water intoxication. This study may have implications for the treatment of addictive behaviour.
(Can J Psychiatry 1996;41:648650)
Key Words: water intoxication, polydipsia, risperidone, clozapine, schizophrenia, addiction

elf-induced water intoxication is a common and serious

problem. Polydipsia occurs in over 20% and water intoxication in up to 5% of chronic psychiatric inpatients, the
majority of whom have schizophrenia (1). Case reports have
indicated clozapine may be beneficial in treating self-induced
water intoxication (25). This raises the hope that we may be
able to treat self-induced water intoxication with serotonin
dopamine antagonists. Clozapine has significant side effects,
however, and is fairly costly.

consumption in patients with chronic schizophrenia and selfinduced water intoxication. We carried out a prospective
open-label study to determine whether risperidone may be
useful in treating the latter condition.
Method
We selected 8 consecutive men (mean age SD = 44.4
9.9 years) who we were starting risperidone treatment and
who met DSM-III-R criteria for chronic schizophrenia. We
obtained written informed consent after giving the subjects a
complete description of the study. Their mean duration of
hospitalization was 16.7 9.0 years. All participants had a
long history of polydipsia and episodic water intoxication.
They had resided on the 25-bed all-male Water Intoxication
Unit at Riverview Hospital for an average of 5.4 3.3 years.
We have characterized patients on this unit in a previous
report (8).

Risperidone is a potent dopamine and serotonin-2A

(5-HT2A) blocker that has been shown to be superior overall
to haloperidol in the management of chronic schizophrenia
(6). A recent case report has described the successful treatment of polydipsia and hyponatremia with risperidone in a
53-year-old man with schizophrenia (7). Clinically, we have
also noted that risperidone seems to decrease fluid

We monitored the fluid intake of the patients for an 8-week

period by weighing them 4 times per day. We calculated the
daily maximum percent increase in body weight with respect
to their 07:30 baseline weight. Serial body weight measurement is a useful way of monitoring changes in hydration (9).
We completed the BPRS for 7 of the 8 men.

Manuscript received February 1996, revised July 1996.

1
Director, Acute Assessment and Treatment Program, Riverview Hospital,
Port Coquitlam, British Columbia.
2
Third-Year Psychiatry Resident, McGill University, Montreal, Quebec.
3
Consulting Psychologist, Riverview Hospital, Port Coquitlam, British
Columbia.
From Riverview Hospital in Port Coquitlam, BC and the Department of
Psychiatry, University of British Columbia, Vancouver, BC.
Address reprint requests to: Dr RC Millson, Riverview Hospital, 500
Lougheed Highway, Port Coquitlam, BC V3C 4J2

We then started them on risperidone in doses up to

16 mg/day. We tapered and then discontinued their previous
antipsychotic medication over 2 weeks. We tried to minimize
changes to their medications over the study period. We

Can J Psychiatry, Vol 41, December 1996

648

December 1996

Self-Induced Water Intoxication

continued to monitor fluid intake by weighing the men 4 times

per day over a 6-month period. We again completed the BPRS
for those assessed previously.
When we started the study, optimal dosing for risperidone
had not been determined. During the study, we learned that
the optimal dose for risperidone was from 6 to 8 mg/day. At
the end of the 6-month period, we decided to extend the study
using the optimal dose. We reduced the patients risperidone
dosage to 8 mg/day. We then waited one month to allow the
patients time to stabilize on the lower dose. Following the
stabilization period, we continued to monitor fluid intake by
weighing the men 4 times per day over a further 2-month
period.
Results
Following the first 6 months of treatment, the mean daily
percent change in body weight declined slightly but not
significantly (baseline [mean SD] = 3.89% 0.81%; after
6 months of risperidone treatment = 3.60% 0.56%; df 7, t =
1.31, P = 0.23). The average risperidone dose was 13 mg over
the 6-month treatment period (range 11 to 15 mg/day). There
was, however, a significant improvement in clinical condition
as assessed by the BPRS (baseline = 24.7 5.6; after 6 months
of risperidone treatment = 14.7 4.8; df 6, t = 3.49, P = 0.013).

to augment the effect of risperidone. This possibility needs to

be explored further.
This study may have theoretical interest in the treatment
of addiction. Although the etiology of self-induced water
intoxication remains unknown, we have suggested that it may
be a form of addictive behaviour (8,10). It has been postulated
that clozapine has an antiaddictive effect in schizophrenia
(11,12). Case reports also suggest clozapine is efficacious in
treating self-induced water intoxication (25). Clozapine and
risperidone have a markedly different spectrum of action on
receptors (13). In particular, risperidone is a much more
potent 5-HT2A blocker (13). Clozapine, in contrast, blocks
muscarinic, 5-HT1, 5-HT2C, and 5-HT3 receptors, none of
which is blocked by risperidone (13). If clozapine proves to
be more efficacious at treating self-induced water intoxication than risperidone, valuable clues may be gained as to
which receptors are important in addiction.

Clinical Implications
Risperidone did not have a significant antipolydipsic effect.
Risperidone may, however, help these patients to be more
amenable to group and behaviour therapy.

Limitations

Following the additional 3 months of treatment at the

lower dose, the mean daily percent change in body weight
slightly declined with respect to baseline, but again, it did not
decline significantly (baseline = 3.89% 0.81%; posttreatment = 3.49% 0.79%; df 7, t = 1.49, P = 0.18). The mean
risperidone dose was 8 mg/day during the last 2 months of the
study.

Open-label, all-male study.

Patients all had a chronic problem with self-induced water
intoxication.

Use of adjunctive agents was not addressed.

Acknowledgement

Discussion
Though there was a trend toward decreased fluid intake,
our clinical impression that risperidone decreased fluid intake
in schizophrenic patients with self-induced water intoxication
was not upheld by our study. Risperidone did have a significant effect, however, in improving clinical status as measured
by the BPRS. The marked improvement in clinical status may
have caused staff to perceive, through a halo effect, that
risperidone was helping patients to decrease their fluid intake
significantly. Risperidone may still be useful in the treatment
of self-induced water intoxication because patients who
suffer fewer psychotic symptoms would be able to derive
greater benefit from group psychotherapy and behaviour
therapy.
It is possible that risperidone may be more efficacious at
a lower dose than we used in this study. It is also possible that
using a large dose of risperidone initially biased the results.
If this were the case, however, we would have expected a
more robust response when we reduced the dose. Our study
does not address the use of adjunctive agents, such as lithium,

649

The authors thank Bradley W Macdonald for help with the data
preparation.

References
1.

de Leon J, Verghese C, Tracy JI, Josiassen RC, Simpson GM. Polydipsia and
water intoxication in psychiatric patients: a review of the epidemiological literature. Biol Psychiatry 1994;35:40819.

2.

Lee HS, Kwon KY, Alphs LD, Meltzer HY. Effect of clozapine on psychogenic
polydipsia in chronic schizophrenia [letter]. J Clin Psychopharmacol 1991;
11:2223.

3.

Spears NM, Leadbetter RA, Shutty MS. Influence of clozapine on water dysregulation [letter]. Am J Psychiatry 1993;150:14301.

4.

Munn NA. Resolution of polydipsia and hyponatremia in schizophrenic patients

after clozapine treatment [letter]. J Clin Psychiatry 1993;54:43940.

5.

de Leon J, Verghese C, Stanilla JK, Lawrence T, Simpson G. Treatment of

polydipsia and hyponatremia in psychiatric patients: can clozapine be a new
option? Neuropsychopharmacology 1995;12:1338.

6.

Marder SR, Meibach RC. Risperidone in the treatment of schizophrenia. Am J

Psychiatry 1994;151:82535.

7.

Landry P. Effect of risperidone on polydipsia and hyponatremia in schizophrenia

[letter]. Can J Psychiatry 1995;40:5667.

8.

Millson RC, Koczapski AB, Cook MI, Daszkiewicz M. A survey of patient

attitudes toward self-induced water intoxication. Can J Psychiatry 1992;37:467.

650

The Canadian Journal of Psychiatry

9.

Delva NJ, Crammer JL. Polydipsia in chronic psychiatric patients: body weight
and plasma sodium. Br J Psychiatry 1988;152:2425.

12.

10.

Ripley TL, Millson RC, Koczapski AB. Self-induced water intoxication and
alcohol abuse. Am J Psychiatry 1988;146:1023.

13.

11.

Albanese MJ, Khantzian EJ, Murphy SL, Green AI. Decreased substance abuse
in chronically psychotic patients treated with clozapine [letter]. Am J Psychiatry
1994;151:7801.

Vol 41, No 10

George TP, Sernyak MJ, Ziedonis DM, Woods SW. Effects of clozapine on
smoking in chronic schizophrenic outpatients. J Clin Psychiatry 1995;56:3446.
Leysen JE, Janssen PM, Megens AAHP, Schotte A. Risperidone: a novel antipsychotic with balanced serotonin-dopamine antagonism, receptor occupancy
profile, and pharmacologic activity. J Clin Psychiatry 1994;55(5 Suppl):5S12S.

Rsum
Objectif : Dterminer lefficacit de la rispridone pour traiter lautointoxication hydrique chez des patients
atteints de schizophrnie chronique.
Mthode : Nous avons men une tude prospective ouverte dune dure de 11 mois sur le traitement la rispridone
de 8 hommes atteints de schizophrnie chronique et dautointoxication hydrique.
Rsultats : Les 8 hommes taient incapables de rduire leur consommation de liquides par comparaison avec leur
apport de dpart. Cependant, la rispridone a beaucoup rduit les scores de ce groupe trs chronique lchelle
abrge dapprciation psychiatrique (Brief Psychiatric Rating Scale, BPRS).
Conclusions : Bien que la rispridone ait rduit les symptmes de schizophrnie, elle nest pas trs efficace pour
traiter lautointoxication hydrique. Cette tude aura peut-tre une incidence sur le traitement dun comportement
pouvant engendrer une dpendance.