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Mood and Behavioral Disturbances in Hospitalized AIDS Patients
Mood and Behavioral Disturbances in Hospitalized AIDS Patients M.D. PHILIP R. MUSKIN, M.D.
CHRISTOPHER JOHANNET,
A retrospective chart review of /27 patients with acquired immune deficiency syndrome (AIDS) was undertaken to determine the rate ofrequests for psychiatric consultation. Thirty-six patients (28.3%) had received psychiatric consultations. This is similar to the rate ofconsultations seen in other studies. Patients who were not intravenous (iv) drug abusers were more likely to be seenfor mood disturbances; iv drug users were more likely to be seen for behavior disturbances. The implications ofthese findings for future demands on consultation-liaison services for AIDS patients are discussed.
A s experience with the acquired immune de.fificiency syndrome (AIDS) continues to increase, it has become apparent that AIDS patients present with a number of psychiatric disorders in addition to the medical complications secondary to human immunodeficiency virus (HIV) infection. Depression, anxiety, delirium, and dementia are among the more common psychiatric disorders encountered.' These disorders have various etiologies, including reactions to the debilitation and stigma of the illness or central nervous system involvement as a result of opportunistic infections, lymphoma, or infection by the AIDS virus itself. i-IS The rate of inpatient psychiatric consultation for hospitalized AIDS patients has varied from 19.2%2 to 32.5%.' Psychiatric consultations are most often requested when patients have symptoms ofdepression, when an evaluation ofsuicide risk is desired, or when patients exhibit behaviors associated with delirium and dementia. 2 In a retrospective chart review, Dilley et aLI found that the rates of mood disturbance (83%) and organic mental syndrome (65%) in hospitalized AIDS patients far exceeded the rate of requests for psychiatric consultation (32.5%). They found four themes were common in AIDS patients: VOLUME3t·NUMBER t·WINTER t990
patients were struggling to deal with a life-threatening illness; patients felt uncertain about the implications of the diagnosis; patients were suffering from social isolation; and patients felt guilty that their previous life-styles had contributed to contracting AIDS.' We undertook this study to examine the psychological morbidity that occurs in hospitalized AIDS patients. To date, AIDS has occurred predominantly among intravenous (iv) drug abusers and homosexual or bisexual men. Other groups at risk of developing AIDS include hemophiliacs, recipients ofblood transfusions, and the sexual partners of at-risk individuals. To further examine the nature of psychiatric disorders in AIDS patients, we questioned whether the disorders experienced by iv drug abusers were different from those
Received March 7, 1988; revised December 28, 1988; accepted January 23, 1989. From the New York State Psychiatric Institute and the Department of Consultation-Liaison Psychiatry, Columbia-Presbyterian Medical Center, New York, New York. Address reprint requests to Dr. Muskin, Department of Consultation-Liaison Psychiatry, Box 427, Columbia-Presbyterian Medical Center. 622 West l68th Street, New York, NY 10032. Copyright © 1990 The Academy of Psychosomatic Medicine.
55
Mood and Behavioral Disturbances in AIDS Patients
experienced by patients in other at-risk groups. Our clinical experience and the literature suggested that psychiatric problems might fall into three broad categories of disturbance in mood. behavior. or cognition. Our chart review yielded insufficient data to estimate the incidence of cognitive impairment. We therefore focused on mood and behavioral disturbances. We defined mood disturbance as feeling sad and anxious; we defined behavioral disturbances as aggressive. assaultive. or disruptive behavior. Because iv drug abusers often present management problems when hospitalized, we speculated that this group would exhibit primarily behavioral disorders. We expected that the other risk groups would present with mood disturbances similar to the reactions of cancer patients. 16 METHODS We reviewed the charts of 176 adult patients hospitalized for AIDS at Columbia-Presbyterian Hospital between June I, 1983. and April 1. 1986. All patients had a confirmed diagnosis of AIDS according to Centers for Disease Control criteria. Complete medical records were available for 127 patients, and we examined these charts for the incidence of psychiatric consultations. All patients had been admitted to medical services. and only patients for whom psychiatric consultations had been specifically requested received psychiatric assessments. The remaining charts contained insufficient data to retrospectively assess psychiatric disorders. Therefore. we feel that using the incidence of psychiatric consultations provides an estimate (possibly an underestimate) of the incidence of psychiatric disorders in this population. I Psychiatric disorders were classified as either behavioral disorders or mood disorders. Behavioral disorders involved behavior that was disruptive to the medical staff and required some kind of intervention, for example, assaulting staff members. ripping out iv lines, smearing feces, and refusing appropriate treabnent. Mood disorders primarily took the form of affective or anxiety disturbances. 56
In either case, the initial complaint may have been for "agitation." If the patient was crying or behaving in a manner that indicated affective instability, he or she would be considered to have a mood disturbance. Agitated patients who had taken a specific disruptive action were considered to have a behavioral disturbance. The one case of a suicide attempt, although a behavior which required staff intervention. was considered a mood disturbance as the patient was depressed and the behavior was mood congruent. RESULTS During the study period, 176 adults were admitted to the medical center with a diagnosis of AIDS. Complete medical records were available for 127 patients. Charts were available for only one out of seven patients who had contracted AIDS as a result of blood transfusion. The charts of these patients were not available for review because the hospital was actively searching for these cases and had removed them from medical records for another project. The patients' mean age was 37.2 years (range, 21 to 69 years). Nine patients were women: four women were iv drug abusers; two developed AIDS from sexual partners; and three were listed as unknown, i.e., no risk factors could be elicited. Forty-three percent of the patients were black. 31 % were Hispanic, 21 % were white, and 2% were listed as "other" in the medical record. The patients' race was unknown in 3% of cases. Distribution of risk factors was similar to the pattern of the known AIDS population as determined by the New York City Department of Health Statistics 17 for August 1986 (see Table I). Thirty-six psychiatric consultations were requested during the study period. Two patients were hospitalized twice and had psychiatric consultations both times. Thus. for 127 patients. the psychiatric consultation rate was 28.3% (see Table 2). To compare the reasons for requesting psychiatric consultations in different risk groups, we compared all other patients who had iv drug abuse as a risk factor with all patients who had received a psychiatric consultation. Patients with PSYCHOSOMATICS
Johannet and Muskin
TABLE I. Percent of AIDS patients at a New York City hospital and in the city generally· with known risk factors for AIDS Hospitalized Patients R1skFaetor
All AIDS Patients (n=176)
Study Group (n=127)b
New York City (n=7,132)
Homosexual
52
57
57.6
Drug abuser (iv)
23 8
20 6
29.3
Transfusion recipient
4
I
0.9
Sexual partner of a person with AIDS
4
6
2.0
Other (unknown)
9
10
5.2
Drug abuser (iv) and homosexual
5.0
·As of July 30.1986; collected by the New York City Department of Health Surveillance" bAlDS patients for whom complete charts were available
TABLE 2. Risk factors for AIDS among AIDS patients for whom psychiatric consultations were sought and reason for consultation Reason for Request Risk Factor
n
%
Homosexual Drug abuser (iv) Drug abuser (iv) and homosexual
20
55.6
6 4
16.7 11.1 2.8
Transfusion recipient Sexual partner of a person with AIDS Other (unknown)
I
2 3
5.6 8.3
Behavior Disturbance
Mood DIsturbance
5 2
17·
3 0 0
I
2
0
3
4 I
"Two patients each had two consultations.
iv drug abuse as a risk factor had five consultations for management of behavior and five consultations for management of mood. Patients who did not have iv drug abuse as a risk factor had five consultations for behavior and 23 consultations for management of mood. This comparison showed a statistical trend, but the difference was not significant (X 2 likelihood ratio=3.66. df= I. p=.055). DISCUSSION The overall rate of requests for psychiatric consultation (28.3%) was similar to that reported from previous studies. I•2 This is a higher rate of requests for psychiatric consultation than has been seen for any other group of hospitalized patients. As a comparison, 5.000 patients were admitted to the Columbia-Presbyterian Medical VOLUME31·NUMBER I·WINTER 1990
Center in 1985. Even if every one of the 800 requests for psychiatric consultations that year were for cancer patients. it would yield a consultation rate of only 16%. AIDS patients have a significant rate of psychological morbidity and an increased need for psychiatric consultations. Because of the projected increases in the incidence of AIDS and concomitant increases in AIDS-related hospitalizations. consultation-liaison services can expect a steadily increasing demand for their resources. Projections of the number of patients who will be hospitalized with AIDS-related illness may be overestimated or underestimated. because they are calculations. not actually reported cases. However. it has been predicted that in New York City between 6.750 and 13,500 patients will be hospitalized with AIDS and AIDS-related illnesses by 1991. 18 This represents 25% to 50% 57
Mood and Behavioral Disturbances in AIDS Patients
of the city's acute care beds. If the rate of request for psychiatric consultation were to reach 26.7% (the average ofthe consultation rates of the other studies l •2 plus our study), at least 1,800 and up to 3,600 AIDS patients alone would be seen by consultation-liaison services in New York City. In a hospital such as Columbia-Presbyterian, the number of psychiatric consultation requests could increase from 800 per year to over 1,000 per year. Specific subgroups had different rates of request for psychiatric consultation. Consultations were requested for 28% of homosexual patients, compared with 23% of iv drug abusers and 50% of homosexual iv drug abusers. While the sample of homosexual iv drug abusers was small, the high rate of requests for psychiatric consultation should alert physicians to their need for psychiatric services. The incidences of mood and behavioral disturbances in iv drug abusers and non-iv drug abusers did not differ to a statistically significant degree, though the trend was clearly in the expected direction. The data do suggest that we can expect a higher proportion of behavioral disturbances in patients who abuse iv drugs than we can expect from other AIDS patients. It also suggests we may see more disturbances in mood in patients who are homosexual than in other AIDS patients. This information may help consultationliaison services develop plans for the future, especially if the distribution of at-risk subgroups of AIDS patients changes, for example, if the proportion of iv drug abusers increases. Our study had several methodological fea-
tures that limit the conclusions that can be drawn from the data. The incidence of requests for psychiatric consultation made by nonpsychiatric physicians provides an estimate of the incidence of psychiatric disorders, but the actual rate may be different. A prospective study with full psychiatric assessment would clearly yield a more accurate rate. Nevertheless, consultation-liaison services receive requests for consultations in proportion to the incidence of symptoms that cause the requesting physician to believe that psychiatric morbidity is present. Even if there are more patients who need psychiatric consultation than there are requests for this service, it remains impressive that such a high proportion ofrequests was made for AIDS patients. Although this study focused on mood and behavioral disturbances, dementias are an important aspect of the disease, and they merit further attention. HIV infection of the central nervous system is extremely common, and it occurs early in the disease process. 19.20 Effects of the virus on the brain are complex and are not easily predicted. AIDS has had a devastating effect on its victims. If consultation-liaison services can develop estimates of future demands on resources, we will be better prepared to meet the challenges this illness presents. If we can predict which subgroups of patients will require more intervention and if we can determine which interventions are likely to yield the maximum benefit, we will be able to utilize limited resources in the most efficient manner.
References I. Dilley JW. Ochitill HN, Perl M.etal: Findings in psychiabic consultations with patients with acquired immune deficiency syndrome. Am J Psychiatry 142:82-86. 1985 2. Perry SW. Tross S: Psychiabic problems of AIDS inpatients at the New York Hospital: preliminary repo". Public Health Rep 99:200-205. 1984 3. Holland IC. Tross S: The psychosocial and neuropsychiabic sequelae of the acquired immunodeficiency syndrome and related disorders. Ann Intern Med 103: 7~764, 1985 58
4. Wolcott DL. Fawzy Fl. Pasnau RO: Acquired immune deficiency syndrome (AIDS) and consultation-liaison psychiatry. Gen Hosp Psychiatry 7:280-292. 1985 5. Faulstich ME: Psychiabic aspects of AIDS. Am J Psychi· atry 144:551-556.1987 6. Cohen MA. Weisman HW: A biopsychosocial approach to AIDS. Psychosomatics 27:245-249. 1986 7. Lowenstein RJ. Sharfson SS: Neuropsychiabic aspects of acquired immune deficiency syndrome. Int J Psychiatry Med 13:255-260. 1984
PSYCHOSOMATICS
Johannet and Muskin
8. Nichols SE, Ostrow DC (eds): Psychiatric Implications ofAcquired Immune Deficiency Syndrome. Washington. DC, American Psychiatric Press, 1984 9. Nichols SE: Psychosocial reactions of persons with the acquired immunodeficiency syndrome. Ann Intern Med 103:765-767.1985 10. Nichols SE: Psychiatric aspects of AIDS. Psychosomatics 24:1083-1089,1983 II. Hoffman PS: Neuropsychiatric complications of AIDS. Psychosomatics 25:393-400, 1984 12. Price W, Forget J: Neuropsychiatric aspects of AIDS: a case repon. Gen Hosp Psychiatry 8:7-10.1986 13. Numberg HG, Prudic J. Fiori M, et a1: Psychopathology complicating acquired immune deficiency syndrome (AIDS). AmI Psychiarry 141:95-96, 1984 14. Kermani EJ, Borod Je, Brown PH. et al: New psychopathologic findings in AIDS: case repon. I Clin Psychiarry 46:240--241. 1985
VOLUME 31 • NUMBER I • WINTER 1990
15. Kennani EJ. Drob S. A1pen N: Organic brain syndrome in three cases of acquired immune deficiency syndrome. Compr Psychiatry 25:294--297. 1984 16. Cassem NH: The dying patient, in Hackel! TP, Cassem NH (eds): Massachusells General Hospital Handbook of General Psychiatry. St Louis. CV Mosby. 1978. pp 300318 17. New York City Depanment of Health: City Health Informarion. vol 5. no 13. New York. New York City Department of Health. August 1986 18. Weinberg OS, Murray HW: Coping with AIDS. N Engl I Med 317: 1469-1474. 1987 19. Gabuzda DH. Hirsch MS: Neurologic manifestations of infection with human immunodeficiency virus. Ann Intern Med 107:383-391,1987 20. Snider WD. Simpson OM, Nielsen S, et al: Neurological complications of acquired immune deficiency syndrome: analysis of 50 patients. Ann Neural 14:403-418. 1983
59
CHRISTOPHER JOHANNET,
A retrospective chart review of /27 patients with acquired immune deficiency syndrome (AIDS) was undertaken to determine the rate ofrequests for psychiatric consultation. Thirty-six patients (28.3%) had received psychiatric consultations. This is similar to the rate ofconsultations seen in other studies. Patients who were not intravenous (iv) drug abusers were more likely to be seenfor mood disturbances; iv drug users were more likely to be seen for behavior disturbances. The implications ofthese findings for future demands on consultation-liaison services for AIDS patients are discussed.
A s experience with the acquired immune de.fificiency syndrome (AIDS) continues to increase, it has become apparent that AIDS patients present with a number of psychiatric disorders in addition to the medical complications secondary to human immunodeficiency virus (HIV) infection. Depression, anxiety, delirium, and dementia are among the more common psychiatric disorders encountered.' These disorders have various etiologies, including reactions to the debilitation and stigma of the illness or central nervous system involvement as a result of opportunistic infections, lymphoma, or infection by the AIDS virus itself. i-IS The rate of inpatient psychiatric consultation for hospitalized AIDS patients has varied from 19.2%2 to 32.5%.' Psychiatric consultations are most often requested when patients have symptoms ofdepression, when an evaluation ofsuicide risk is desired, or when patients exhibit behaviors associated with delirium and dementia. 2 In a retrospective chart review, Dilley et aLI found that the rates of mood disturbance (83%) and organic mental syndrome (65%) in hospitalized AIDS patients far exceeded the rate of requests for psychiatric consultation (32.5%). They found four themes were common in AIDS patients: VOLUME3t·NUMBER t·WINTER t990
patients were struggling to deal with a life-threatening illness; patients felt uncertain about the implications of the diagnosis; patients were suffering from social isolation; and patients felt guilty that their previous life-styles had contributed to contracting AIDS.' We undertook this study to examine the psychological morbidity that occurs in hospitalized AIDS patients. To date, AIDS has occurred predominantly among intravenous (iv) drug abusers and homosexual or bisexual men. Other groups at risk of developing AIDS include hemophiliacs, recipients ofblood transfusions, and the sexual partners of at-risk individuals. To further examine the nature of psychiatric disorders in AIDS patients, we questioned whether the disorders experienced by iv drug abusers were different from those
Received March 7, 1988; revised December 28, 1988; accepted January 23, 1989. From the New York State Psychiatric Institute and the Department of Consultation-Liaison Psychiatry, Columbia-Presbyterian Medical Center, New York, New York. Address reprint requests to Dr. Muskin, Department of Consultation-Liaison Psychiatry, Box 427, Columbia-Presbyterian Medical Center. 622 West l68th Street, New York, NY 10032. Copyright © 1990 The Academy of Psychosomatic Medicine.
55
Mood and Behavioral Disturbances in AIDS Patients
experienced by patients in other at-risk groups. Our clinical experience and the literature suggested that psychiatric problems might fall into three broad categories of disturbance in mood. behavior. or cognition. Our chart review yielded insufficient data to estimate the incidence of cognitive impairment. We therefore focused on mood and behavioral disturbances. We defined mood disturbance as feeling sad and anxious; we defined behavioral disturbances as aggressive. assaultive. or disruptive behavior. Because iv drug abusers often present management problems when hospitalized, we speculated that this group would exhibit primarily behavioral disorders. We expected that the other risk groups would present with mood disturbances similar to the reactions of cancer patients. 16 METHODS We reviewed the charts of 176 adult patients hospitalized for AIDS at Columbia-Presbyterian Hospital between June I, 1983. and April 1. 1986. All patients had a confirmed diagnosis of AIDS according to Centers for Disease Control criteria. Complete medical records were available for 127 patients, and we examined these charts for the incidence of psychiatric consultations. All patients had been admitted to medical services. and only patients for whom psychiatric consultations had been specifically requested received psychiatric assessments. The remaining charts contained insufficient data to retrospectively assess psychiatric disorders. Therefore. we feel that using the incidence of psychiatric consultations provides an estimate (possibly an underestimate) of the incidence of psychiatric disorders in this population. I Psychiatric disorders were classified as either behavioral disorders or mood disorders. Behavioral disorders involved behavior that was disruptive to the medical staff and required some kind of intervention, for example, assaulting staff members. ripping out iv lines, smearing feces, and refusing appropriate treabnent. Mood disorders primarily took the form of affective or anxiety disturbances. 56
In either case, the initial complaint may have been for "agitation." If the patient was crying or behaving in a manner that indicated affective instability, he or she would be considered to have a mood disturbance. Agitated patients who had taken a specific disruptive action were considered to have a behavioral disturbance. The one case of a suicide attempt, although a behavior which required staff intervention. was considered a mood disturbance as the patient was depressed and the behavior was mood congruent. RESULTS During the study period, 176 adults were admitted to the medical center with a diagnosis of AIDS. Complete medical records were available for 127 patients. Charts were available for only one out of seven patients who had contracted AIDS as a result of blood transfusion. The charts of these patients were not available for review because the hospital was actively searching for these cases and had removed them from medical records for another project. The patients' mean age was 37.2 years (range, 21 to 69 years). Nine patients were women: four women were iv drug abusers; two developed AIDS from sexual partners; and three were listed as unknown, i.e., no risk factors could be elicited. Forty-three percent of the patients were black. 31 % were Hispanic, 21 % were white, and 2% were listed as "other" in the medical record. The patients' race was unknown in 3% of cases. Distribution of risk factors was similar to the pattern of the known AIDS population as determined by the New York City Department of Health Statistics 17 for August 1986 (see Table I). Thirty-six psychiatric consultations were requested during the study period. Two patients were hospitalized twice and had psychiatric consultations both times. Thus. for 127 patients. the psychiatric consultation rate was 28.3% (see Table 2). To compare the reasons for requesting psychiatric consultations in different risk groups, we compared all other patients who had iv drug abuse as a risk factor with all patients who had received a psychiatric consultation. Patients with PSYCHOSOMATICS
Johannet and Muskin
TABLE I. Percent of AIDS patients at a New York City hospital and in the city generally· with known risk factors for AIDS Hospitalized Patients R1skFaetor
All AIDS Patients (n=176)
Study Group (n=127)b
New York City (n=7,132)
Homosexual
52
57
57.6
Drug abuser (iv)
23 8
20 6
29.3
Transfusion recipient
4
I
0.9
Sexual partner of a person with AIDS
4
6
2.0
Other (unknown)
9
10
5.2
Drug abuser (iv) and homosexual
5.0
·As of July 30.1986; collected by the New York City Department of Health Surveillance" bAlDS patients for whom complete charts were available
TABLE 2. Risk factors for AIDS among AIDS patients for whom psychiatric consultations were sought and reason for consultation Reason for Request Risk Factor
n
%
Homosexual Drug abuser (iv) Drug abuser (iv) and homosexual
20
55.6
6 4
16.7 11.1 2.8
Transfusion recipient Sexual partner of a person with AIDS Other (unknown)
I
2 3
5.6 8.3
Behavior Disturbance
Mood DIsturbance
5 2
17·
3 0 0
I
2
0
3
4 I
"Two patients each had two consultations.
iv drug abuse as a risk factor had five consultations for management of behavior and five consultations for management of mood. Patients who did not have iv drug abuse as a risk factor had five consultations for behavior and 23 consultations for management of mood. This comparison showed a statistical trend, but the difference was not significant (X 2 likelihood ratio=3.66. df= I. p=.055). DISCUSSION The overall rate of requests for psychiatric consultation (28.3%) was similar to that reported from previous studies. I•2 This is a higher rate of requests for psychiatric consultation than has been seen for any other group of hospitalized patients. As a comparison, 5.000 patients were admitted to the Columbia-Presbyterian Medical VOLUME31·NUMBER I·WINTER 1990
Center in 1985. Even if every one of the 800 requests for psychiatric consultations that year were for cancer patients. it would yield a consultation rate of only 16%. AIDS patients have a significant rate of psychological morbidity and an increased need for psychiatric consultations. Because of the projected increases in the incidence of AIDS and concomitant increases in AIDS-related hospitalizations. consultation-liaison services can expect a steadily increasing demand for their resources. Projections of the number of patients who will be hospitalized with AIDS-related illness may be overestimated or underestimated. because they are calculations. not actually reported cases. However. it has been predicted that in New York City between 6.750 and 13,500 patients will be hospitalized with AIDS and AIDS-related illnesses by 1991. 18 This represents 25% to 50% 57
Mood and Behavioral Disturbances in AIDS Patients
of the city's acute care beds. If the rate of request for psychiatric consultation were to reach 26.7% (the average ofthe consultation rates of the other studies l •2 plus our study), at least 1,800 and up to 3,600 AIDS patients alone would be seen by consultation-liaison services in New York City. In a hospital such as Columbia-Presbyterian, the number of psychiatric consultation requests could increase from 800 per year to over 1,000 per year. Specific subgroups had different rates of request for psychiatric consultation. Consultations were requested for 28% of homosexual patients, compared with 23% of iv drug abusers and 50% of homosexual iv drug abusers. While the sample of homosexual iv drug abusers was small, the high rate of requests for psychiatric consultation should alert physicians to their need for psychiatric services. The incidences of mood and behavioral disturbances in iv drug abusers and non-iv drug abusers did not differ to a statistically significant degree, though the trend was clearly in the expected direction. The data do suggest that we can expect a higher proportion of behavioral disturbances in patients who abuse iv drugs than we can expect from other AIDS patients. It also suggests we may see more disturbances in mood in patients who are homosexual than in other AIDS patients. This information may help consultationliaison services develop plans for the future, especially if the distribution of at-risk subgroups of AIDS patients changes, for example, if the proportion of iv drug abusers increases. Our study had several methodological fea-
tures that limit the conclusions that can be drawn from the data. The incidence of requests for psychiatric consultation made by nonpsychiatric physicians provides an estimate of the incidence of psychiatric disorders, but the actual rate may be different. A prospective study with full psychiatric assessment would clearly yield a more accurate rate. Nevertheless, consultation-liaison services receive requests for consultations in proportion to the incidence of symptoms that cause the requesting physician to believe that psychiatric morbidity is present. Even if there are more patients who need psychiatric consultation than there are requests for this service, it remains impressive that such a high proportion ofrequests was made for AIDS patients. Although this study focused on mood and behavioral disturbances, dementias are an important aspect of the disease, and they merit further attention. HIV infection of the central nervous system is extremely common, and it occurs early in the disease process. 19.20 Effects of the virus on the brain are complex and are not easily predicted. AIDS has had a devastating effect on its victims. If consultation-liaison services can develop estimates of future demands on resources, we will be better prepared to meet the challenges this illness presents. If we can predict which subgroups of patients will require more intervention and if we can determine which interventions are likely to yield the maximum benefit, we will be able to utilize limited resources in the most efficient manner.
References I. Dilley JW. Ochitill HN, Perl M.etal: Findings in psychiabic consultations with patients with acquired immune deficiency syndrome. Am J Psychiatry 142:82-86. 1985 2. Perry SW. Tross S: Psychiabic problems of AIDS inpatients at the New York Hospital: preliminary repo". Public Health Rep 99:200-205. 1984 3. Holland IC. Tross S: The psychosocial and neuropsychiabic sequelae of the acquired immunodeficiency syndrome and related disorders. Ann Intern Med 103: 7~764, 1985 58
4. Wolcott DL. Fawzy Fl. Pasnau RO: Acquired immune deficiency syndrome (AIDS) and consultation-liaison psychiatry. Gen Hosp Psychiatry 7:280-292. 1985 5. Faulstich ME: Psychiabic aspects of AIDS. Am J Psychi· atry 144:551-556.1987 6. Cohen MA. Weisman HW: A biopsychosocial approach to AIDS. Psychosomatics 27:245-249. 1986 7. Lowenstein RJ. Sharfson SS: Neuropsychiabic aspects of acquired immune deficiency syndrome. Int J Psychiatry Med 13:255-260. 1984
PSYCHOSOMATICS
Johannet and Muskin
8. Nichols SE, Ostrow DC (eds): Psychiatric Implications ofAcquired Immune Deficiency Syndrome. Washington. DC, American Psychiatric Press, 1984 9. Nichols SE: Psychosocial reactions of persons with the acquired immunodeficiency syndrome. Ann Intern Med 103:765-767.1985 10. Nichols SE: Psychiatric aspects of AIDS. Psychosomatics 24:1083-1089,1983 II. Hoffman PS: Neuropsychiatric complications of AIDS. Psychosomatics 25:393-400, 1984 12. Price W, Forget J: Neuropsychiatric aspects of AIDS: a case repon. Gen Hosp Psychiatry 8:7-10.1986 13. Numberg HG, Prudic J. Fiori M, et a1: Psychopathology complicating acquired immune deficiency syndrome (AIDS). AmI Psychiarry 141:95-96, 1984 14. Kermani EJ, Borod Je, Brown PH. et al: New psychopathologic findings in AIDS: case repon. I Clin Psychiarry 46:240--241. 1985
VOLUME 31 • NUMBER I • WINTER 1990
15. Kennani EJ. Drob S. A1pen N: Organic brain syndrome in three cases of acquired immune deficiency syndrome. Compr Psychiatry 25:294--297. 1984 16. Cassem NH: The dying patient, in Hackel! TP, Cassem NH (eds): Massachusells General Hospital Handbook of General Psychiatry. St Louis. CV Mosby. 1978. pp 300318 17. New York City Depanment of Health: City Health Informarion. vol 5. no 13. New York. New York City Department of Health. August 1986 18. Weinberg OS, Murray HW: Coping with AIDS. N Engl I Med 317: 1469-1474. 1987 19. Gabuzda DH. Hirsch MS: Neurologic manifestations of infection with human immunodeficiency virus. Ann Intern Med 107:383-391,1987 20. Snider WD. Simpson OM, Nielsen S, et al: Neurological complications of acquired immune deficiency syndrome: analysis of 50 patients. Ann Neural 14:403-418. 1983
59