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HIV-dementia and suicide
HIV-Dementia and Suicide Cesar A. Alfonso, M.D. and Mary Ann Adler Cohen, M.D.
Case Reports
from jail. He has a history of polysubstance abuse and dependence including inhalants since age 8, cannabis since age 12, and “crack” cocaine, intravenous heroin, and cocaine since age 29. His first suicide attempt occurred 7 months after learning of his HIV seropositivity. He was admitted to our medical intensive care unit with pulmonary edema after self-inflicted intravenous injections of an organophosphate insecticide. Psychiatric evaluation revealed psychomotor retardation, affective lability, suicidal ideation, global memory dysfunction, concrete thinking, and regressed behavior, including spitting and urinating on the floor. Head computed tomographic (CT) scan showed cortical atrophy. CD4KD8 ratio was 0.66. He was transferred to psychiatry and stabilized on haloperidol, 5 mg twice a day, and supportive psychotherapy and remained for 1 month but was lost to follow up. Six months later, he attempted suicide for the second time. He was admitted to medicine with sepsis after mutilating his penis with repeated injections of an organophosphate insecticide. Psychiatric evaluation revealed marked poverty of speech, increased affective lability and irritability, suicidal ideation, extreme difficulty processing information, and minimal understanding of the need for treatment. CD4/CD8 ratio was 0.46. He was placed on continuous suicide watch but absconded from the hospital and was lost to follow-up.
Cllse 1
Case 2
Mr. A is a 32-year-old man who learned of his HIV seropositive status 1 month prior to his release
Ms. B. is a 37-year-old woman with a history significant for alcohol dependence and intravenous use of heroin and cocaine. After numerous unsuccessful attempts at achieving sobriety throughout most of her adult life, she became drug-free only after learning of her HIV seropositivity. She was
Abstract: Suicide is dementia. lmpulsivity, inhibition are associated two suicidal individuals
a dangerous concomitant of HIVimpaired judgment, lability, and diswith dementia. The authors describe
with HIV-dementia.
Introduction Some studies indicate a higher risk for suicide in persons with HIV infection [1,2]. Alienation and expendability are consistent themes for persons with HIV infection, and a natural concomitant is the thought of suicide [3]. Suicidal ideation can occur at any time, from realization of being at risk, learning of HIV seropositivity, onset of first symptoms, diagnosis of first opportunistic infection, to end-stage illness. Suicidal@ is exacerbated by psychiatric disorders, especially depression, dementia, and substance abuse. HIV-dementia is associated with behavioral disinhibition, memory impairment, and impulsivity. Chronic and debilitating illnesses such as Huntington’s disease [4] have an increased rate of suicide. Huntington’s and AIDS are associated with subcortical dementia and may make individuals more vulnerable to suicide. Disinhibition and impaired cognitive function diminish a person’s capacity to understand and cope with the vicissitudes of AIDS. The following cases will illustrate these issues.
New York Medical College, Metropolitan Hospital Center, New York, New York. Address reprint requests to: Mary Ann Adler Cohen, M.D., 220 West 93rd Street, Apartment 14A, New York, 10025.
General Hospital Psychiatry 16, 4546, 1994 0 1994 Elsevier Science Inc. 655 Avenue of the Americas, New York, NY 10010
45 ISSN 0163~8343/941$7.00
C. A. Alfonso and M. A. A. Cohen
actively involved in 12-step programs and remained sober for 4 years. Her CD4 count was 334. Computed tomographic scan of the head revealed generalized cortical atrophy, and lumbar puncture revealed elevated protein. She developed apathy, lethargy, word-finding difficulty, memory deficits, and difficulty modulating her emotional responses. As HIV-dementia worsened, she began to think about killing herself by medication overdose. This was the first time in her life that she had suicidal ideation. Psychiatric examination revealed disorientation to time, affective lability, global memory dysfunction, dysnomia, concrete thinking, and suicidal thoughts. She was started on haloperidol, 0.5 mg at bedtime, individual psychotherapy, family therapy, and attends a weekly HIV support group in addition to 1Zstep groups.
Discussion Our case reports illustrate that suicidal ideation and behavior can be dangerous concomitants of HIV-dementia. Firesetting is another unexpected manifestation of HIV-dementia and has been described [5] in three of our patients who were not suicidal, although one died as a result of his burns. We feel that HIV-dementia heightens the risk of suicide in people who are HIV seropositive or who have AIDS. Our retrospective study [l] of psychiatric consultations indicated that suicidal behavior was present in one of every five persons with HIV seropositivity or AIDS. A recent national study [2] of death certificates revealed a 7.4-fold higher rate of suicide in persons with AIDS. Our case reports illustrate suicidal behavior or ideation in two individuals who were not depressed but had clinical evidence of HIV-dementia. Both had psychomotor retardation, global memory impairment, concrete thinking, affective lability, irritability, and word-finding difficulty. The behavioral disinhibition associated with subcortical dementia combines with impulsivity to put patients with HIV-dementia at particular risk for suicide. Substance abuse intensified the risk of suicide in our patients. Mr. A’s antisocial personality
46
features were exacerbated by HIV-dementia. His continued use of substances after he developed AIDS emphasizes the multifactorial nature of his suicidal behavior. Ms. B achieved and maintained sobriety and had no evidence of underlying personality disorder. Both patients had evidence of HIV-dementia before they developed suicidality. Mr. A developed suicidal behavior and made two suicide attempts, whereas Ms. B developed preoccupation with the idea of committing suicide. Dementia was associated with suicidal behavior in hospitalized medical and surgical patients [6] even prior to the HIV epidemic, although one study of psychiatric patients [7] and another of general care patients [8] do not illustrate a significant correlation. Our case reports suggest that studies of a correlation between HIV-dementia and suicide are needed. Our findings indicate the importance of recognition of HIV-dementia and the need for caregivers to be alert to the dangerous concomitant of suicide.
References 1. Alfonso CA, Cohen MA, Aladjem AD, et al: Is HIV seropositivity a major risk factor for suicide in the general hospital? Psychosomatics 1994 (in press) 2. Cote TR, Biggar RJ, Dannenberg AL: Risk of suicide among persons with AIDS; a national assessment. JAMA 268:206&2068, 1992 3. Cohen MA: Biopsychosocial aspects of the HIV epidemic. In Wormser GP (ed), AIDS and Other Manifestations of HIV Infection. New York, Raven Press Ltd., 1992, pp 349-371 4. Schoenfeld M, Myers RH, Cupples LH: Increased rate of suicide among patients with Huntington’s disease. J Neurol Neurosurg Psychiatry 47:1283-1287, 1984 5. Cohen MA, Aladjem AD, Brenin D, Ghazi M: Firesetting by patients with the acquired immunodeficiency syndrome (AIDS). Ann Intern Med 112:386387, 1990 6. Reich I’, Kelly MJ: Suicide attempts by hospitalized medical and surgical patients. N Engl J Med 294:29% 301, 1976 7. Black DW, Warrack B, Winokur G: The Iowa RecordLinkage Study II: excess mortality among patients with organic mental disorders. Arch Gen Psychiatry 42:78-81, 1985 8. McKegney FP, O’Dowd MA: Suicidality and HIV status. Am J Psychiatry 149:39&398, 1992
Case Reports
from jail. He has a history of polysubstance abuse and dependence including inhalants since age 8, cannabis since age 12, and “crack” cocaine, intravenous heroin, and cocaine since age 29. His first suicide attempt occurred 7 months after learning of his HIV seropositivity. He was admitted to our medical intensive care unit with pulmonary edema after self-inflicted intravenous injections of an organophosphate insecticide. Psychiatric evaluation revealed psychomotor retardation, affective lability, suicidal ideation, global memory dysfunction, concrete thinking, and regressed behavior, including spitting and urinating on the floor. Head computed tomographic (CT) scan showed cortical atrophy. CD4KD8 ratio was 0.66. He was transferred to psychiatry and stabilized on haloperidol, 5 mg twice a day, and supportive psychotherapy and remained for 1 month but was lost to follow up. Six months later, he attempted suicide for the second time. He was admitted to medicine with sepsis after mutilating his penis with repeated injections of an organophosphate insecticide. Psychiatric evaluation revealed marked poverty of speech, increased affective lability and irritability, suicidal ideation, extreme difficulty processing information, and minimal understanding of the need for treatment. CD4/CD8 ratio was 0.46. He was placed on continuous suicide watch but absconded from the hospital and was lost to follow-up.
Cllse 1
Case 2
Mr. A is a 32-year-old man who learned of his HIV seropositive status 1 month prior to his release
Ms. B. is a 37-year-old woman with a history significant for alcohol dependence and intravenous use of heroin and cocaine. After numerous unsuccessful attempts at achieving sobriety throughout most of her adult life, she became drug-free only after learning of her HIV seropositivity. She was
Abstract: Suicide is dementia. lmpulsivity, inhibition are associated two suicidal individuals
a dangerous concomitant of HIVimpaired judgment, lability, and diswith dementia. The authors describe
with HIV-dementia.
Introduction Some studies indicate a higher risk for suicide in persons with HIV infection [1,2]. Alienation and expendability are consistent themes for persons with HIV infection, and a natural concomitant is the thought of suicide [3]. Suicidal ideation can occur at any time, from realization of being at risk, learning of HIV seropositivity, onset of first symptoms, diagnosis of first opportunistic infection, to end-stage illness. Suicidal@ is exacerbated by psychiatric disorders, especially depression, dementia, and substance abuse. HIV-dementia is associated with behavioral disinhibition, memory impairment, and impulsivity. Chronic and debilitating illnesses such as Huntington’s disease [4] have an increased rate of suicide. Huntington’s and AIDS are associated with subcortical dementia and may make individuals more vulnerable to suicide. Disinhibition and impaired cognitive function diminish a person’s capacity to understand and cope with the vicissitudes of AIDS. The following cases will illustrate these issues.
New York Medical College, Metropolitan Hospital Center, New York, New York. Address reprint requests to: Mary Ann Adler Cohen, M.D., 220 West 93rd Street, Apartment 14A, New York, 10025.
General Hospital Psychiatry 16, 4546, 1994 0 1994 Elsevier Science Inc. 655 Avenue of the Americas, New York, NY 10010
45 ISSN 0163~8343/941$7.00
C. A. Alfonso and M. A. A. Cohen
actively involved in 12-step programs and remained sober for 4 years. Her CD4 count was 334. Computed tomographic scan of the head revealed generalized cortical atrophy, and lumbar puncture revealed elevated protein. She developed apathy, lethargy, word-finding difficulty, memory deficits, and difficulty modulating her emotional responses. As HIV-dementia worsened, she began to think about killing herself by medication overdose. This was the first time in her life that she had suicidal ideation. Psychiatric examination revealed disorientation to time, affective lability, global memory dysfunction, dysnomia, concrete thinking, and suicidal thoughts. She was started on haloperidol, 0.5 mg at bedtime, individual psychotherapy, family therapy, and attends a weekly HIV support group in addition to 1Zstep groups.
Discussion Our case reports illustrate that suicidal ideation and behavior can be dangerous concomitants of HIV-dementia. Firesetting is another unexpected manifestation of HIV-dementia and has been described [5] in three of our patients who were not suicidal, although one died as a result of his burns. We feel that HIV-dementia heightens the risk of suicide in people who are HIV seropositive or who have AIDS. Our retrospective study [l] of psychiatric consultations indicated that suicidal behavior was present in one of every five persons with HIV seropositivity or AIDS. A recent national study [2] of death certificates revealed a 7.4-fold higher rate of suicide in persons with AIDS. Our case reports illustrate suicidal behavior or ideation in two individuals who were not depressed but had clinical evidence of HIV-dementia. Both had psychomotor retardation, global memory impairment, concrete thinking, affective lability, irritability, and word-finding difficulty. The behavioral disinhibition associated with subcortical dementia combines with impulsivity to put patients with HIV-dementia at particular risk for suicide. Substance abuse intensified the risk of suicide in our patients. Mr. A’s antisocial personality
46
features were exacerbated by HIV-dementia. His continued use of substances after he developed AIDS emphasizes the multifactorial nature of his suicidal behavior. Ms. B achieved and maintained sobriety and had no evidence of underlying personality disorder. Both patients had evidence of HIV-dementia before they developed suicidality. Mr. A developed suicidal behavior and made two suicide attempts, whereas Ms. B developed preoccupation with the idea of committing suicide. Dementia was associated with suicidal behavior in hospitalized medical and surgical patients [6] even prior to the HIV epidemic, although one study of psychiatric patients [7] and another of general care patients [8] do not illustrate a significant correlation. Our case reports suggest that studies of a correlation between HIV-dementia and suicide are needed. Our findings indicate the importance of recognition of HIV-dementia and the need for caregivers to be alert to the dangerous concomitant of suicide.
References 1. Alfonso CA, Cohen MA, Aladjem AD, et al: Is HIV seropositivity a major risk factor for suicide in the general hospital? Psychosomatics 1994 (in press) 2. Cote TR, Biggar RJ, Dannenberg AL: Risk of suicide among persons with AIDS; a national assessment. JAMA 268:206&2068, 1992 3. Cohen MA: Biopsychosocial aspects of the HIV epidemic. In Wormser GP (ed), AIDS and Other Manifestations of HIV Infection. New York, Raven Press Ltd., 1992, pp 349-371 4. Schoenfeld M, Myers RH, Cupples LH: Increased rate of suicide among patients with Huntington’s disease. J Neurol Neurosurg Psychiatry 47:1283-1287, 1984 5. Cohen MA, Aladjem AD, Brenin D, Ghazi M: Firesetting by patients with the acquired immunodeficiency syndrome (AIDS). Ann Intern Med 112:386387, 1990 6. Reich I’, Kelly MJ: Suicide attempts by hospitalized medical and surgical patients. N Engl J Med 294:29% 301, 1976 7. Black DW, Warrack B, Winokur G: The Iowa RecordLinkage Study II: excess mortality among patients with organic mental disorders. Arch Gen Psychiatry 42:78-81, 1985 8. McKegney FP, O’Dowd MA: Suicidality and HIV status. Am J Psychiatry 149:39&398, 1992