Unlocking Behaviors: Fluid Seeking

By Ley Linder, MA, M. Ed, BCBA and Craig Escudé, MD, FAAFP, FAADM

This article is part of a co-authored series on behavioral presentations in which a physician and a behavior analyst provide insight into real-life case studies to share their expertise on how behavioral issues can be addressed in an interdisciplinary fashion. Escudé and Linder are the proud recipients of the 2024 AADMD Excellence in IDD Journalism Award for this ongoing series.

George is a 49-year-old man with a moderate intellectual disability who communicates with short phrases, comprehends simple verbal communication, and is quite observant of his environment. When he moved to his new home approximately 12 months ago, he had a limited medical history, but diagnoses of iron deficiency, allergies, gastroesophageal reflux disease (GERD), constipation, and an unspecified fluid restriction of 1500 mL (1.5 L) per day were noted. He also arrived taking seven psychotropic medications, plus another for the side effects of these medications.

Periodically, staff members have reported that George exhibits changes in his behaviors, such as staying in the bathroom for long periods, having difficulty walking, and “seeming out of it.”  In the last month, George had two incidents where he became highly agitated and aggressive towards his housemates and walked away from his home to a convenience store. At the convenience store, he continued to be aggressive to community members and employees, as well as “chugging gallons of milk,” his favorite drink. Law enforcement officers were called on both occasions, and George was detained and issued no-trespassing orders.

George has, once again, been referred to the psychiatrist from his recent visits to the Emergency Room, where he was seen for behavioral instability. George is seeing a new psychiatric team that declines to increase any psychiatric medications, advocates for a long-term plan to decrease the number of psychotropic medications, and recommends a global review of his medical and behavioral needs.

Medical Discussion

Did you say seven psychotropics? I wonder how any of us would feel on seven serious medications with complex interactions and side effect profiles.

Polydipsia is an abnormal urge to drink lots of fluids most or all the time. One medical condition that can cause people to feel excessively thirsty is uncontrolled diabetes. When a person’s blood glucose remains above 200, the glucose spills over into their urine, taking fluid with it. This results in excessive fluid loss and constant thirst. Once a person’s blood glucose is controlled, the excessive thirstiness resolves.

George should be checked for diabetes, but the pattern of fluid ingestion speaks to something a bit different. Psychogenic polydipsia is associated with some mental health disorders and can result in compulsive water drinking. Drinking excessive water can also result in a “drunk” feeling that may be desirable to some. Additionally, drinking lots of water can affect the body’s electrolyte balance, particularly causing hyponatremia (low sodium). When a person’s blood sodium level drops to around 120 or lower, it can cause seizures and pose a risk of death. This is a medical emergency. The first order of business for George is to make sure he is medically stable and check his sodium levels.

Other signs of water intoxication include nausea, vomiting, delirium, ataxia, seizures, and coma. Psychogenic polydipsia is seen more commonly in people with chronic schizophrenia, affective disorders, intellectual disability, personality disorders, and anxiety. Many antipsychotic medications have anticholinergic properties that can cause excessive thirst as well. Still, the description of George’s compulsive water drinking leans more towards it being related to a mental health or developmental condition.

Behavioral Discussion

We often hear the adage “think medical first” when we are assessing behavioral issues, particularly for people with comorbidities. As noted by Dr. Escudé, polypharmacy also has a noteworthy impact when looking at behavior presentations. As behavior analysts, we are often trained to think of behaviors in a singular, formulaic fashion that focuses on a linear understanding of behavior – Setting Event > Antecedent > Behavior > Consequence. However, this process does not always lead to understanding complex medical issues.

One way to think medically is to look at the various components that comprise the totality of a person. In George’s case, this would be the behavioral changes (agitation, aggression, elopement, and staying in the bathroom for long periods), cognitive status changes (e.g., “he’s out of it”), physical changes (e.g., gait changes/stumbling), and his medical needs (e.g., diagnoses and medications). If only looking at behavioral changes, we, as behavior analysts, would not be accounting for the interconnected and varying dynamics of all parts of a person that impact behavior.

At times, behavior analysts' goal is not to solve the problem. Our role can be to compile information, utilizing the input of other disciplines, to help the entire interdisciplinary team develop a better understanding of behavioral presentations. We do this by looking beyond behavior and connecting the dots across the various components that make up a person.   

Outcome

After the third instance of law enforcement being called, the interdisciplinary team “started over” and looked at all the possibilities to explain the sudden change in cognitive status and rapid escalation of aggressive behaviors. The first question asked by the behavior analyst was, “Why would a person be restricted to only 1500 mL of liquid per day?”  Pulling this thread unwound a long history (not known before admission) of George being treated for hyponatremia. With the help of the nursing staff, the behavior analyst developed a “behavior symptom profile” of hyponatremia and trained staff to recognize the possible signs. The next time George displayed the noted behaviors and characteristics, he was taken to the hospital to check his sodium levels. You guessed it. George needed IV fluids, not a court date.

About the Authors

Ley Linder, MA, M. Ed, BCBA is a Board-Certified Behavior Analyst with an academic and professional background in gerontology and applied behavior analysis. Ley’s specialties include behavioral gerontology and the behavioral presentations of neurocognitive disorders, in addition to working with high-management behavioral needs for dually diagnosed persons with intellectual disabilities and mental illness. He works closely with national organizations such as the National Down Syndrome Society and the National Task Group on Intellectual Disabilities and Dementia Practices. He is the Founder/CEO of Crescent Behavioral Health Services based in Columbia, SC.

Craig Escudé, MD, FAAFP, FAADM is a board-certified Fellow of the American Academy of Family Physicians and the American Academy of Developmental Medicine, and President of IntellectAbility. He has more than 20 years of clinical experience providing medical care for people with IDD and complex medical and mental health conditions. He is the author of “Clinical Pearls in IDD Healthcare” and developer of the “Curriculum in IDD Healthcare,” an eLearning course used to train clinicians on the fundamentals of healthcare for people with IDD, and the host of the IDD Health Matters Podcast.