Scott Eliason, MD, CCHP-MH, Regional Psychiatric Director for Idaho through Corizon Correctional Health Care talks about polydipsia, its various manifestations, and management in the correctional setting. He presented this topic along with Mark Fleming, PhD, CCHP-MH at the 2015 NCCHC Spring Conference on Correctional Health Care in New Orleans, April 11-14. 
Psychogenic polydipsia, excessive fluid-seeking, is a life-threatening condition that is more common than believed and very difficult to manage in the correctional environment. The excess water consumed in this state leads to hyponatremia; a diluted sodium level. The low sodium then results in water intoxication; a condition that causes neurological symptoms as the brain swells with fluid. Patients exhibit behavior changes, confusion, slurred speech, and, if left untreated, progress to seizures and death.

Causes

Excessive thirst can result from the hyperglycemia of untreated diabetes, a significant blood loss, dehydration, or bodily fluid shift such as from kidney failure. This symptom resolves once the condition is managed and fluid balance returns to normal. Psychogenic polydipsia, however, is a condition of psychological rather than physiologic origin. When the intake of water exceeds the body’s ability to manage it, imbalance ensues.

Schizophrenia is one of the most common causes of psychogenic polydipsia with as many as 20% of schizophrenic patients having some periods of polydipsia and up to 5% compulsively drinking enough water to lead to self-induced water intoxication.

Even higher rates of polydipsia are found in individuals who are schizophrenic and are also anorexic, have seizures, or are substance abusers. Then, too, medications such as carbamazepine (Tegretol), oxcarbazepine (Trileptal), and fluozetine (Prozac), part of many mental health treatment plans can lower sodium levels. Plus, so many medication have dry mouth as a side effect; increasing the desire to drink.

Management Priorities

When treating psychogenic polydipsia, Dr. Eliason likes to start by reviewing the patient’s list of medications to see if any can be adjusted or replaced. He has seen some success with adding clozaril (Clozapine) to decrease water seeking behavior. Although the mechanism is unknown, adding a beta blocker to the regimen may be helpful, as well.

While medication adjustments help long-term outcomes, water restriction is the best treatment for the acute phase of water intoxication. Sodium levels usually correct naturally in a couple days. Significantly low sodium levels need close monitoring in an acute care setting; sometimes even critical care.

Treatment Challenges

The compulsive nature of psychogenic polydipsia combined with restrictions of the correctional environment make treatment difficult. Releasing chronic water seekers from water restriction is tricky. Dr. Eliason describes an inmate’s situation of being locked in a cell with a sink and a toilet as the equivalent of locking an alcoholic in a bar.

Dr. Eliason has had success with excess drinking behavior management through a daily weight monitoring regimen. A patient’s weight is usually baseline in the morning as the body has re-equilibrated overnight. Then, during the day the patient over-hydrates resulting in water weight gain. A weight gain of 4% typically equates to a 10 meq blood sodium reduction. By using a morning and evening weight as a feedback mechanism, a patient can be moved in and out of water restriction status until able to self-manage the desire to drink. As can be expected, a team effort is needed to make this work. Both officers and health care staff must be observant of the regimen over time.

 

Have you had a patient who could not control their water drinking? How was it handled in your setting?