Water feature: A brief look at psychogenic polydipsia, hyponatraemia, and ‘aquaholism’

Over the weekend I went to the cinema with my oldest son to watch Mad Max: Fury Road. The reason I mention this is because King Immortan Joe in the film (who live in a world where water is a scarce commodity) tells his thirsty subjects “Do not become addicted to water, it will take hold of you”. As soon as I got home after the film, I was straight onto Google and Google Scholar to see whether there had been anything written on ‘water addiction’. Unsurprisingly, there were lots of newspaper reports of individuals being ‘addicted’ to water but little in the academic literature. For instance, one American online article told the story of Sasha Kennedy:

“[Sasha] is addicted to water, drinking 25 liters of the stuff a day, far exceeding the USDA Recommended Daily Water Intake of 2.7 liters…What surprised me most was that the condition had a name: Psychogenic polydipsia. It is ‘an uncommon clinical disorder characterized by excessive water-drinking in the absence of a physiologic stimulus to drink’ and is typically found among mental patients on phenothiazine medications. Kennedy appears to be completely sane, although she does experience the dry mouth sensation characteristic of the condition…You’d think drinking so much water would do something to her health, but medical experts confirmed that there is nothing wrong with her. She doesn’t even have hypoatremia, where cells swell due to too much water in the blood. She’s perfectly healthy and her blood isn’t diluted. Then again, her habit started when she was two years old, so maybe her body acclimatized. Her lifestyle, however, is drastically affected by her addiction. She has to go to the toilet 40 times a day and can only get about an hour of sleep every night before having to wake up to drink some water or go to the loo. She carries large bottles of water with her everywhere she goes, and once quit her job because the tap water quality wasn’t up to par”.

Another case was reported by the UK’s Daily Mail who recounted the story of 22-year old “aquaholic” Sarah Schapira who (at the time the article was written) drank seven litres of water every day, and like Sasha above spent a lot of time in the toilet. Schapira stated:

“My argument has always been that water is good for you and helps you to detox. We’ve all been told about the benefits of water, so I drink lots and lots of it, from the minute I wake up to the minute I go to bed. If I don’t have my bottle of water I feel paranoid. And if I try not to drink for an hour, I start to feel dehydrated and I get throbbing headaches. But it has got to the stage where I don’t know how to give it up. It used to make me feel really good and healthy but not any more. I know I ought to cut down but I’m not sure how I can”.

Polydipsia (which in practical terms means drinking more than three litres of water a day) often goes hand-in-hand with hyponatraemia (i.e., low sodium concentration in the blood) and in extreme cases can lead to excessive water drinkers slipping into a coma. The low levels of sodium causes the brain to swell which in turn constricts the blood supply to the brain when the brain compresses against the skull’s inner surface. Another person interviewed for the Daily Mail story was 26-year-old Rachel Bennett, a marketing agent from North London who drank also drank seven litres of water a day which led to headaches and dizziness. She said:

“My friends used to tease me about the amount I drank, but I dismissed their fears because I always thought it was so good for me. It got to the stage where I felt I couldn’t function without it. If I woke without a bottle of water by my bed, I would feel really paranoid. I couldn’t drink tap water – that tasted awful – instead I drank Evian by the gallon. It’s expensive, too – I could spend over £30 a week on water – but I had got to the stage where I got a huge buzz from drinking so much”.

In researching this article, I was surprised to find dozens and dozens of academic papers on psychogenic polydipsia (PPD). For instance, a paper by Dr. Brian Dundas and colleagues in a 2007 issue of Current Psychiatry Reports noted that PPD is a clinical syndrome characterized by polyuria (constantly going to the toilet) and polydipsia (constantly drinking too much water), and is common among individuals with psychiatric disorders. They also noted that:

“The underlying pathophysiology of this syndrome is unclear, and multiple factors have been implicated, including a hypothalamic defect and adverse medication effects. Hyponatremia in PPD can progress to water intoxication and is characterized by symptoms of confusion, lethargy, and psychosis, and seizures or death. Evaluation of psychiatric patients with polydipsia warrants a comprehensive evaluation for other medical causes of polydipsia, polyuria, hyponatremia”.

A 2000 study in European Psychiatry by Dr. E. Mercier-Guidez and Dr. G. Loas examined water intoxication in 353 French psychiatric inpatients. They reported that water intoxication can lead to irreversible brain damage and that around one-fifth of deaths among schizophrenics below the age of 53 years are caused this way. The study reported that 38 of the psychiatric patients (11%) suffered from polydipsia with one-third of them at risk of water intoxication. They also reported that being polydipsic was significantly associated with being male, a cigarette smoker and celibate. Those with polydipsia were highly prevalent among those with schizophrenia, mental retardation, pervasive developmental disorders and somatic disorders.

A comprehensive review by Dr. Victor Vieweg and Dr. Robert Leadbetter in the journal CNS Drugs examined the polydipsia-hyponatraemia syndrome (PHS). They reported that PHS occurs in approximately 5%-10% of institutionalised, chronically psychotic patients, of which four-fifths have schizophrenia. Major clinical features are polydipsia and dilutional hyponatraemia. Patents with PHS can experience delirium, generalised seizures, coma and death. The main ways to treat such individuals are fluid restriction, daily bodyweight monitoring, behavioural approaches, and supplemental oral sodium chloride administration. However, these interventions can be expensive as they require experienced and dedicated multidisciplinary staff. They also report that:

“A number of pharmacological treatments have been assessed for PHS including the combination of lithium and phenytoin, demeclocycline, propranolol, ACE inhibitors, selective serotonin (5-hydroxytryptamine; 5-HT) reuptake inhibitors, typical antipsychotic drugs, clozapine and risperidone. Of these agents, the most promising are the combination of lithium and phenytoin, and clozapine…Long term strategies include behavioural interventions and the combination of lithium and phenytoin, and clozapine”.

Unsurprisingly, I found almost nothing on being addicted to water. A 2010 review article on PPD by Dr. D. Hutcheon and Dr. M. Bevilacqua in the Annals of the American Psychotherapy Association claimed:

“One way to assess a patient’s ability to limit polydipsia is to examine their objective reasons why polydipsia is so important in their lives. This can be initiated during psychosocial rehabilitation group meetings held semi-weekly (e.g., two 15-minute sessions per week). In these meetings, many patients have described a euphoric quality associated with polydipsia, although others have admitted to increased irritability. Most patients have noted a desire for stimulation, similar to other substances of abuse such as alcohol or street drugs. Developing an understanding of what influences a patient to develop an addiction for polydipsia can improve management of this dysregulation of fluid intake…During the treatment period in a structured inpatient setting, many patients diagnosed with psychogenic polydipsia, whether falling in the range of mild, moderate, or severe addiction, are unable to sustain a comfortable discharge to an open ward…psychogenic polydipsia can become an addiction with no demonstrable cure if left untreated… Due to the nature of the addiction and potential for self-injurious behavior, treatment requires a milieu that balances maximizing the patients’ dignity with their safety, which demands close scrutiny by the multidisciplinary team”.

I also found an old case study from a 1973 issue of the British Journal of Addiction on ‘water dependence’. This paper reported that the excessive drinking of water can dilute electrolytes in an individual’s brain and cause intoxication. A couple of papers by Dr. Bennett Foddy and Dr. Julian Savulescu have cited this case study in their own writings on addiction. In a 2010 issue of Philosophy, Psychiatry and Psychology, they noted:

“Of course, it can be claimed that a person who is addicted to sugar or water is diseased, and that their brain has changed in such a way as to make their sugar- or water-seeking behavior involuntary. Yet we know how sugar interacts with the brain to form a sensitization effect, and it is identical to how drugs – and sugar – interact with the brain of a non-addicted person. If addictions are formed through a pharmacological process, it is the exact same process that forms a person’s likes and dislikes of any pleasurable stimulus. Terms like ‘addiction’ and ‘dependence’ can reasonably be employed when a person’s likes become particularly strong, but it should be understood that these terms denote a difference in degree, not a difference in kind…The only relevant difference between drugs and sugar is that drugs produce a higher level of brain reward relative to the volume of the dose. It is easier to get addicted to heroin than to sugar, because you can do it by taking a quarter gram at a time. It is very hard to get addicted to water, because you must force down liters of it every day”.

This interesting extract argues that it is theoretically possible for someone to become addicted to water and that there is no real difference to drug addictions in terms of conceptualization and mechanism – just that the sheer amount of water that needs to be drunk to have a negative effect is large and highly unlikely.

Dr. Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Daily Mail (2005). Aquaholics: Addicted to drinking water. May 16. Located at: http://www.dailymail.co.uk/health/article-348917/Aquaholics-Addicted-drinking-water.html

de Leon, J., Verghese, C., Tracy, J. I., Josiassen, R. C., & Simpson, G. M. (1994). Polydipsia and water intoxication in psychiatric patients: a review of the epidemiological literature. Biological Psychiatry, 35(6), 408-419.

Dundas, B., Harris, M., & Narasimhan, M. (2007). Psychogenic polydipsia review: etiology, differential, and treatment. Current Psychiatry Reports, 9(3), 236-241.

Edelstein, E.L. (1973). A case of water dependence. British Journal of Addiction to Alcohol and Other Drugs, 68, 365–367.

Foddy, B., & Savulescu, J. (2007). Addiction is not an affliction: Addictive desires are merely pleasure-oriented desires. American Journal of Bioethics, 7(1), 29-32

Foddy, B., & Savulescu, J. (2010). A liberal account of addiction. Philosophy, Psychiatry, and Psychology, 17(1), 1-22.

Hutcheon, D., & Bevilacqua, M. (2010). Psychogenic polydipsia: A review of past and current interventions for treating psychiatric inpatients diagnosed with psychogenic polydipsia (PPD). Annals of the American Psychotherapy Association, 13(1). Located at: http://www.biomedsearch.com/article/Psychogenic-polydipsia-review-past-current/222558218.html

Teoh, S.Y. (2012). Woman addicted to water drinks 100 glasses a day. The Mary Sue, July 12. Located at: http://www.themarysue.com/woman-addicted-to-water/#geekosystem

Vieweg, W.V.R., & Leadbetter, R.A. (1997). Polydipsia-Hyponatraemia Syndrome. CNS Drugs, 7(2), 121-138.

Verghese, C., de Leon, J., & Josiassen, R. C. (1996). Problems and progress in the diagnosis and treatment of polydipsia and hyponatremia. Schizophrenia Bulletin, 22(3), 455-464.

About drmarkgriffiths

Professor MARK GRIFFITHS, BSc, PhD, CPsychol, PGDipHE, FBPsS, FRSA, AcSS. Dr. Mark Griffiths is a Chartered Psychologist and Professor of Behavioural Addiction at the Nottingham Trent University, and Director of the International Gaming Research Unit. He is internationally known for his work into gambling and gaming addictions and has won many awards including the American 1994 John Rosecrance Research Prize for “outstanding scholarly contributions to the field of gambling research”, the 1998 European CELEJ Prize for best paper on gambling, the 2003 Canadian International Excellence Award for “outstanding contributions to the prevention of problem gambling and the practice of responsible gambling” and a North American 2006 Lifetime Achievement Award For Contributions To The Field Of Youth Gambling “in recognition of his dedication, leadership, and pioneering contributions to the field of youth gambling”. His most recent award is the 2013 Lifetime Research Award from the US National Council on Problem Gambling. He has published over 600 research papers, four books, over 130 book chapters, and over 1000 other articles. He has served on numerous national and international committees (e.g. BPS Council, BPS Social Psychology Section, Society for the Study of Gambling, Gamblers Anonymous General Services Board, National Council on Gambling etc.) and is a former National Chair of Gamcare. He also does a lot of freelance journalism and has appeared on over 2000 radio and television programmes since 1988. In 2004 he was awarded the Joseph Lister Prize for Social Sciences by the British Association for the Advancement of Science for being one of the UK’s “outstanding scientific communicators”. His awards also include the 2006 Excellence in the Teaching of Psychology Award by the British Psychological Society and the British Psychological Society Fellowship Award for “exceptional contributions to psychology”.

Posted on May 26, 2015, in Addiction, Case Studies, Compulsion, Drug use, Gender differences, Obsession, Psychiatry, Psychological disorders, Psychology, Unusual deaths and tagged , , , , , , , , , , , , . Bookmark the permalink. Leave a comment.

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