A brief look at psychogenic polydipsia, hyponatraemia, and ‘aquaholism’
In May 2015, I went to the cinema with my oldest son to watch Mad Max: Fury Road. The reason I mention this is because one of the characters in the film (who live in a world where water is a scarce commodity) tells someone else not to become“addicted to water”. 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’.
Dr. Mark Griffiths is a Distinguished Professor of Behavioural Addiction and Director of the International Gaming Research Unit in the Psychology Department at Nottingham Trent University (UK). He has published over 620 refereed research papers, five books, 150+ book chapters, and over 1,500 other articles, and has won 18 national and international awards for his research.
Editor: Nadeem Noor
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 hyponatremia, 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 recounted the story of 22-year old “aquaholic” Sarah Schapira who drinks seven liters of water every day, and like Sasha above spends 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 anymore. 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 liters of water a day) often goes hand-in-hand with hyponatremia (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 cause 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 liters 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 the 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). 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, 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-hyponatremia syndrome (PHS). They reported that PHS occurs in approximately 5%-10% of institutionalized, chronically psychotic patients, of which four-fifths have schizophrenia. Major clinical features are polydipsia and dilutional hyponatremia. Patents with PHS can experience delirium, generalized seizures, coma, and death. The main ways to treat such individuals are a fluid restriction, daily bodyweight monitoring, behavioral 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 is the combination of lithium phenytoin and clozapine…Long-term strategies include behavioral 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 a case study from a 1973 issue of the British Journal of Addiction on ‘water dependence’. This paper reported that 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.