Can you really get too much water? Based on the current literature encouraging people to hydrate, hydrate, hydrate, you wouldn’t think so. However, we need to be aware that some of our patients are dying from too much water. Here are just two examples from a Michigan prison and from the San Diego Central Jail. Considered a rare condition in the community, the potential for water intoxication, also called psychogenic polydipsia (PPD), is very real in correctional settings. Correctional nurses and our officer colleagues need to be aware of this condition and act quickly if it occurs to save lives.

Many years ago, I was working in a prison in the South that had housing units with no air-conditioning, in the summer heat, and so everyone was encouraged to drink water. A correctional officer working in the mental health housing unit noticed an inmate who began drinking water uncontrollably. This officer realized that the patient’s water intake was above and beyond what everyone else in the housing unit was drinking, and asked the mental health nurse to evaluate the situation. This case had a good outcome in that the patient was evaluated and a PPD diagnosis was made early before things got out of hand. Unfortunately, as you can read in the accounts of the water intoxication deaths in Michigan and California, all too often the condition is not detected or managed well.

What is Water Intoxication?

Simply put, water intoxication is drinking more water than the body can physiologically handle. This fluid overload affects the electrolyte balance in the body by causing sodium levels and plasma osmolality to drop beyond what can normally be handled by the kidneys. Below are some physical signs of hyponatremia caused by water intoxication:

• Abdominal distention
• Eye puffiness
• Extremity edema
• Headache
• Dizziness
• Nausea
• Vomiting

The electrolyte imbalance also causes behavior and affect changes, but these can easily be mistaken for the usual signs and symptoms of an underlying mental disorder:

• Anger outbursts
• Irritability
• Pacing
• Restlessness
• Confusion

Rapid fluid shifts in the brain can lead to seizures, coma, and death. This is a serious condition that needs early diagnosis and treatment.

Who is Prone to This Condition?

In both these cases, the patient had schizophrenia. Indeed, up to 20% of psychiatric patients can have PPD. The increased proportion of mental illness in the incarcerated patient population is a major factor in the frequency of water intoxication accounts in correctional practice.

The following categories of patients are also prone to hyponatremia:

• Users of ecstasy (MDMA) and other street drugs
• People with schizophrenia (thirst is a common side effect of certain medications)
• People with eating disorders
• Patients on Total Parenteral Nutrition (TPN)
• Individuals involved in heavy physical activity, like endurance athletes and soldiers doing military training

While most correctional nurses will not be managing patients on TPN, drug use is high in the incarcerated population, and some athletic competitions among incarcerated persons can get out of hand. Mainly, though, this condition will occur in the psychiatric patient population. It is notable that many of the symptoms of PPD are also symptoms of dehydration, and so it is vitally important that you complete a thorough assessment of your patient, including a complete health history and physical evaluation, and have a consultation with a provider before deciding your patient needs to be encouraged to drink more water.

What is the Treatment for Water Intoxication?

Managing water intoxication can be difficult.  Here are some suggestions from psychiatrists Perch and O’Connor.

• Don’t judge: In a PPD situation, drinking water is an uncontrollable compulsion, not a manageable behavior. Gain rapport by being nonjudgmental and understanding of the patient’s struggle.
• Monitor patient’s weight: Daily morning weights can be used to provide feedback on water intake. In this Correctional Nursing Today podcast, psychiatrist Scott Eliason discusses how he uses this intervention in his work with patients in the Idaho Correctional system.
• Restrict but don’t eliminate fluids: Maintain hydration with 2-3 liters of fluid daily but do not eliminate fluids totally. If a dry cell is used, close monitoring is necessary to assure that proper hydration continues.
• Review psychotropic medication: A psychiatrist may be able to alter the type of medications to ease compulsive fluid intake.
• Use positive reinforcement: Higher functioning patients may benefit from a reward system for fluid intake compliance.

Have you ever had a patient with water intoxication in your setting? Share your experiences in the comments section of this post.