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Psychiatric Care for Patients With HIV Infection
Perspective Psychiatric Care for Patients With HIV Infection The Varying Perspectives GLENN
J. TREISMAN M.D., PH.D., CONSTANTINE G. LYKETsos, M.D. MARE FISHMAN, M.D., ANNETTE L. HANSON, M.D. ADAM ROSENBLATT, M.D., PAUL R. McHUGH, M.D.
This article reviews the literature on the classification and treatment ofpsychiatric morbidity associated with infection from the human immunodeficiency virus (HW). The psychiatric disorders seen in HW-infected patients are formulated by using one ofthe following four perspectives as treatment guides: J) the syndromal or disease perspective, 2) the dispositional or personality perspective. 3) the behavioral or addictive perspective, and 4) the life story perspective.
Received May I. 1992; revised June 5. 1992; accepted November 17. 1992. From The AIDS Psychiatry Service. Depanrnent of Psychiatry and Behavioral Sciences. The Johns Hopkins University School of Medicine. Address reprint requests to Dr. Treisman. The AIDS Psychiatry Service. Depanrnent of Psychiatry and Behavioral Sciences. Meyer 4-119.600 North Wolfe Street. Baltimore. MD 21287-7419. Copyright © 1993 The Academy of Psychosomatic Medicine. 432
PSYChiatriC care has become an integral part of the care of human immunodeficiency virus (HIV)-infected patients, especially given the substantial psychiatric morbidity encountered in this patient population. A variety of approaches to psychiatric evaluation, diagnosis, and treatment have been applied with varying degrees of success. A bibliography on psychiatric disorders and treatment in HIV-infected patients has been compiled recently.1 This article summarizes our experience in a general medical clinic caring for HIV-infected patients, both as providers of primary psychiatric care and as outpatient and inpatient consultants throughout the Johns Hopkins Hospital. Our approach is organized around the perspectives described by McHugh and Slavney,2 a series of methods that categorize the problems seen in psychiatric patients. Each perspective brings to the patient its own unique logic and set of priorities and directs treatment in a particular way. Depending on the problem, one or more of the perspectives may be more salient in formulating a particular treatment approach for a patient. Patients can be seen as having any combination of four different types of disorders: I) the syndromal or disease category in which disorders arise because of a "broken part" in their physiologic makeup; 2) the behavioral or addictive disorders in which problems arise when motivational drives go awry; 3) the PSYCHOSOMATICS
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dispositional or personality disorders, where difficulties emerge from an individual's temperament; and 4) disorders that stem from achange in a person's life circumstances and the individual's difficulties in coping with them. DISEASE AND SYNDROMAL DISORDERS Syndromally defined major mental illnesses are the first focus of our discussion. The high prevalence of these disorders that we discerned in our patients matches several published studies showing that individuals in the HIV high-risk categories suffer from an increased lifetime prevalence of major mental illness, especially major depression and anxiety disorders. In homosexual men who are uninfected or early in the course of mv infection, there is an increased lifetime prevalence of both affective disorders and anxiety disorders.3-S In clinics where drug abuse is the primary focus for treabnent, there is a 20%-30% comorbid diagnosis of affective disorder in the absence of mv infection as well as an increase in the rates of schizophrenia and other disorders6 (L. Cottier, personal communication, November 1991). Major Depression Depressed mood is the most common reason for psychiatric referral in our HIV medical clinic and elsewhere.7-14 It is a feature of many disorders, including major depression, grieving, and demoralization or adjusbnent disorder. Major depression is the most commonly diagnosed psychiatric disorder in several clinics. I 5-16 In HIV-infected patients, it appears in its classic form,I7 with severely depressed mood, anhedonia, hopelessness, helplessness, poor self-attitude, and attendant neurovegetative phenomena. It is difficult at times to decide whether vegetative signs stem from the depression or are a result of the HIV infection itself. Therefore, exclusive reliance on their presence to diagnose depression is not suggested. Rather, the clinician should look for accompanying "cognitive" symptoms of depression and changes in self-attitude. The most common neurovegetative features are diurnal mood variation, anorexia, weight loss, cognitive impairment, psychomotor retardation, impaired libido, and sleep disturbance with early morning awakening. We have seen an increased incidence of major depression late in the course of HIV infection, and the emergence of this syndrome is correlated with low CD4 counts and the development of AIDS. 16 Although the demoralization related to the awareness and progression of illness might be mistaken for major depression, the correct diagnosis is usually clear when these classic symptoms cluster into a full syndrome of major depression. These cases follow the typical natural history of the syndrome as well as the expected response to treabnent. VOLUME 34 • NUMBER S• SEPrEMBFR - OCTOBER 1993
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We have been impressed by the response to medications in this patient population and have seen an 85% response to treatment in our clinic, with a 50% complete recovery rate in patients treated with antidepressants. 16 We favor profile drugs that have low side effects, such as nortriptyline, desipramine, and fluoxetine, but we have had a good response in patients with most of the antidepressants we have used. In addition, we have needed to develop therapeutic plasma levels in patients to obtain a response and frequently need to try several drugs to get a profile of side effects that the patient can tolerate. Insomnia from fluoxetine has responded to low-dose trazodone (25-50 mg po qhs), and other side effects, such as dry mouth and constipation, decrease when increased fluid intake is encouraged. As has been reported elsewhere, we have found that the use of low-dose psychostimulants in some of the amotivational or apathetic states, or in the most refractory depressions, may be useful. Most important is the need to "start low and go slow" to minimize the increased number of side effects that patients may experience. In addition, we have treated several patients with lithium to "augment" the effects of antidepressants, achieving good success in those who previously had responded marginally to treatment. Several authors report similar results in patients who responded to a wide range of medications and electroconvulsive therapy. 18-23 Delirium. Dementia, and "Psychotic" Disorders Delirium is a common diagnosis in HIV-infected patients in both outpatient and inpatient settings.11.1 3.24-25 This disorder presents in a variety of ways and frequently mimics other psychiatric disorders. The primary distinguishing characteristics are a fluctuation in level of consciousness and symptoms (the so-called "waxing and waning" mental state) as well as a "clouding" of consciousness that interferes with attention. Although a complete discussion of this topic is beyond our scope, a full evaluation of delirium is in order because outcome is heavily influenced by a prompt, accurate diagnosis of the underlying cause. An EEG can be extremely useful in clari434
fying this diagnosis in difficult cases. Specific temporizing treatments with very low-dose neuroleptic agents (0.5-1 mg of haloperidol po, im, or iv qhs) may be helpful if control of delusions or hallucinations, and/or if behavioral management. is the goal. 24 Dementia is also a common diagnosis and presents with the typical manifestations of subcortical dementia with impairment of memory and attention, apathy. amotivation, and general cognitive decline. 9.26--46 Screening evaluations with the Mini-Mental State Exam and written or verbal "trailmaking" tests are fast and useful ones that can be used at the bedside. Although dementia usually is a prognostically grim sign, treatment with zidovudine (AZT) has been useful and has significantly altered the course of dementia. particularly if begun early.47 Psychotic disorders, such as schizophrenia, delusional disorder, and transient atypical episodes, are seen in HIV-infected patients.6.IO.12.48-54 Most are associated with substance use/abuse or withdrawal, although some appear indistinguishable from the disorders seen in non-HIV populations. Epidemiologic evidence suggests that the latter occur with frequencies similar to the general population and most clinical studies support this. ss-56 Treatment then is similar to that used in other settings, with antipsychotics, supportive psychotherapy, and rehabilitative efforts all being crucial elements. 3s,SI,S7-ss We have seen a rate of manic episodes almost 10 times that of the general population in patients with AIDS. Half of the cases are in patients with personal and family backgrounds of affective disorder. The other half are patients late in the course of progression of AIDS who have developed mild or moderate dementia and who do not have personal or family histories of affective disorder. S9 Several others report similar findings, which suggests "that mania may be a late-stage "neuropsychiatric"complication ofthe infection.4s .6O-{)2 Management consists mainly of high-potency antipsychotics such as haloperidol because lithium is generally too toxic at the levels needed to be effective. We have avoided carbarnazepine and valproic acid because they pose a significant risk of myelosuppression in imPSYCHOSOMATICS
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munocompromised patients already taking agents such as AZT. SUBSTANCE USE AND OTHER BEHAVIORAL DISORDERS Although several features of HIV-infected patients contribute to the development and maintenance ofbehavioral disorders, these disorders are perhaps best dealt with as primary diagnoses. 2 Nationally, roughly one-half of new diagnoses of AIDS are related in some way to substance abuse. and this is the most rapidly increasing problem in our clinic and also poses a risk factor for the disease.6.63-«J The major difference with the disease perspective is that the behavioral disorder itself is seen as the patient's major difficulty regardless of what led to its development. The behavioral disorder is not assumed to be the result of a "broken part" in the body as would be the case in a disease. What causes a behavioral disorder is different from what sustains it. Attention is directed at the elements of habit, such as hunger, drive, conditioning, reward, and relative salience, that sustain the disorder. This reasoning in tum directs the primary goal of treatment, which is to stop the behavior and then to deal with comorbid disease, personality vulnerability, and life story issues. Although we are currently unable to provide adequate treatment resources in our clinic, we have been most successful when patients were approached with an integrated treatment plan, formulated according to American Psychiatric Association recommendations. This approach has proven effective in the treatment of patients with addiction problems regardless of HIV statuS. 67 All providers are involved in formulating a plan and the patient is "won over" to cooperate in a series of psychotherapeutic sessions often involving our "confrontation with a smile" approach. Patients are shown gradually that they have lost control of their behavior and that they must stop the behavior to avoid facing serious consequences. They are further persuaded that, in their best interest, they must relinquish control to the treatment team and follow their recommendations for a period of time. VOLUME 34 • NUMBER 5 • SEPTEMBER - ocrOBER 1993
The treatment involves three phases: 1) detoxification, 2) monitored maintenance with preparation for relapse, and 3) elimination of contributing comorbidity. The first phase is to stop the behavior. We have used both inpatient and outpatient approaches in this phase. Treatment of withdrawal symptoms, support for acute intoxication, and encouragement are all necessary. The second treatment phase involves all members of the clinic and is aimed at providing encouragement to the patient during a difficult time, particularly during relapse. A therapeutic contract, frequent urine toxicology screens, and involvement of family and housing providers are useful in maintaining medication and treatment compliance. We also rely heavily on the use of community resources, such as Alcoholics Anonymous, Narcotics Anonymous, and a variety of support groups, to aid our patients. Last, we have found that frequent, brief visits to assess the patient's progress and to monitor drug/alcohol abstinence are of vital importance. The third treatment phase includes the diagnosis of comorbid conditions, such as depression, personality disorder, and medical illness, that predispose an individual to substance abuse. It may be necessary to directly prescribe changes in social networks. jobs, or living situations. As difficult as such changes may be, they are often necessary to remove the patient from highly conditional cues. We have found that treatment of substance abuse, paraphilia, and other behavioral disorders as primary diagnoses has led to a dramatic improvement in both psychiatric and physical outcome for many of our difficult cases. PERSONALITY VULNERABILITY AND TEMPERAMENT DISORDERS We have defined vulnerabilities in a person's personality as those that emerge when a patient's life circumstances change, ones that negatively affect a patient who is psychologically and/or temperamentally unprepared to deal with the change in circumstances. 2 Impulsiveness, overdramatization, poor recognition of future consequences of current behavior, and inability to tolerate discomfort or delay all contribute to risk 435
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factors for HIV infection. 68 Therefore, it is not surprising that we see a high incidence of personality vulnerability in our clinic patients. In severe cases, these vulnerabilities lead to a sustained effect on the patients' behavior, to the degree that they meet criteria for personality disorder, according to DSM-III-R criteria. We have seen all types of character disorder, but mainly we see patients with features described as histrionic, antisocial, and borderline. We approached treatment in much the same way shown to produce good results elsewhere. s8 ,64 This approach is threefold: I) develop a therapeutic plan, 2) provide psychotherapy, and 3) treat the comorbid conditions. Involvement ofthe entire treatment team to prevent "splitting," identification of target symptoms and behaviors, and placing firm limits with fixed consequences that are agreed on in advance all are mainstays of the therapeutic plan. Cognitive and supportive psychotherapy directed at identifying for patients their vulnerabilities and assets has been our most useful technique. We use our previously described confrontation approach to remind patients that tolerating discomfort and inconvenience may have far better consequences than acting out their impulses. Comorbid conditions have already been described as accompanying personality disorder diagnoses in general, such as anxiety disorders, mood disorders, and substance abuse disorders. The percentage of these disorders we have found in our clinic are similar to those reported in other settings,6S and we find that treatment of the comorbid conditions is essential for treatment success. Although, as expected, the rate of successful treatment (i.e., reduction of psychiatric symptoms, improved compliance, and less explosiveness in the clinic) of personality disorder in our clinic is lower than for other diagnoses, we have had striking case success with this approach. LIFE CIRCUMSTANCE AND SITUATION The final and perhaps most crucial issue to address regarding psychiatric care in this population pertains to life circumstances. Loss of 436
physical and cognitive ability, as well as the loss of friends and even certain freedoms, may contribute to the demoralization and grieving that commonly occurs in these patients. These issues have been elaborated on by Viederman and Perry69 in their discussion of the meaning of disease within the individual's life story. Although there are the obvious comparisons to be made with and lessons to be learned from other medical clinics, such as cancer and chronic renal failure, certain problems are unique to our patient population. The stigma of being homosexual or an intravenous drug abuser may antedate the infection and is further compounded by the presence of a highly stigmatizing disease. This places AIDS patients in the paradoxical situation of having a certain and increasing need for services while being most at risk for having these services denied. 29 ,7G-74 Surprisingly, in spite of the presence of these difficulties, most of our patients cope well with the discomforts of their disease. 7s-n Group and supportive psychotherapy is helpful to many patients78-81 and is provided to patients in need in our clinic with good results. A complicating factor in distressed patients is the distinction between depression and demoralization. Patients face the "Damoclean" reality of living with the terminal uncertainties of HIV infection in the prime of life and endure progressive loss of the ability to function. Also, they suffer the need to depend increasingly on others for basic daily activities and are the victims of countless explicit and implicit prejudicial societal attitudes and the discriminatory practices of some institutions. In light of this, we have frequently jumped to the explanation that our patients are depressed because of the change in their life circumstances. It was not until we saw the good response rates mentioned in the frrst section of our discussion that we became more aggressive in the use ofmedications. These results differ from the experience in treating oncology and chronic renal failure patients in that we see a much higher rate of response to medication in mY-infected patients. 82--M While remaining empathetic, we have had to be careful not to be convey a "too understanding" attitude that might convey that depressive symptoms are an inevitaPSYCHOSOMATICS
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ble consequences of a tragic change in life circumstances rather than manifestations of a treatable affective disease. Therefore, we use careful diagnostic evaluation, close follow-up, and provide psychotherapy, as well as medication in those patients of unclear diagnosis. The more clearly demoralized patients usually respond well to psychotherapy. An approach to therapy similar to that already well described by other authors for other chronic diseases and HIV infection can be used to significantly improve both medication/treatment compliance and the quality of life for HIV-infected individuals. 69•78-80 CONCLUSION Our experience in caring for HIV-infected patients with psychiatric morbidity mandates careful diagnosis and formulation prior to initiation of treatment. One of the difficulties in managing complex patients with multiple problems is that
each new case tends to appear as a unique set. or tangle, of signs and symptoms. The use of several perspectives in formulating each patient approach 2 has improved our ability to organize treatment. By differentiating disorders using these perspectives. we have been able to identify recurring clinical patterns that encompass our patients' complicated and often chaotic problems. Careful evaluation for the presence of diseases, behavioral disorders, disorders of temperament, and disorders related to life circumstance has allowed us to make diagnoses, target treatments, and test hypotheses according to familiar principles. As a result. our patients' disorders have improved as have their compliance with medical treatment and their overall quality of life. Finally, recognition of these perspectives and their application to clinical care settings promotes the development of coherent research strategies in consultation-liaison psychiatry.
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morbidity of mY-infected soldiers. Hosp Community Psychiatry 1991; 42:619-623 55. Regier DA, Boyd JH, Burke ro, et a1: One-month prevalence of mental disorders in the United States. Arch Gen Psychiatry 1988; 45:977-986 56. Robins LN, Helzer JE, Weissman MM, et a1: Lifetime prevalence of specific psychiatric disorders in three sites. Arch Gen Psychiatry 1984; 41 :949-958 57. Perry SW, Markowitz J: Psychiatric interventions for AIDS spectrum disorders. Hosp Community Psychiatry 1986; 37:1001-1006 58. Wolcott DL, Fawzy R, Namir S: Clinical management of psychiatric disorders in HIV spectrum disease. Psychiatr Med 1989; 7:107-127 59. Lyketsos CG, Hanson AL, Fishman M, et a1: Mania early and late in the course of mv infection. Am J Psychiatry 1993; 150:326-327 60. Schmidt U, Miller D: Two cases of hypomania in AIDS. Br J Psychiatry 1988; 152:839-842 61. Gabel RH, Barnard N, Narko M, et a1: AIDS presenting as mania. Compr Psychiatry 1986; 27:251-254 62. Kierburtz K, Zettelmaier AE, Ketonen A, et a1: Manic syndrome in AIDS. Am J Psychiatry 1991; 48: 1068-1070 63. Ravin DK, Franklin IE, Frances RJ: The acquired immune deficiency syndrome (AIDS) and suicidal behavior in a1cohol-dependent homosexual men. Am J Psychiatry 1986; 143:1440-1442 64. Guydish J, Temoshok L, Dilley J, et a1: Evaluation of a hospital-based substance abuse intervention and referral service for HIV-infected patients. Gen Hosp Psychiatry 1990; 12:1-7 65. Ross HE, Glaser FB, Germanson T: The prevalence of psychiatric disorders in patients with alcohol and other drug problems. Arch Gen Psychiatry 1988; 45: I 023-1031 66. Rounsaville BJ, Weissman MM. Crits-etuistoph K, et a1: Diagnosis and symptoms of depression in opiate addicts. Arch Gen Psychiatry 1982; 39:151-156 67. American Psychiatric Association: APA Task Force on the Treaunent of Psychiatric Disorders. Washington, DC, American Psychiatric Press, 1989. pp 1430-1447 68. Gilben JG, Lombardi DN: Personality characteristics of young male narcotic addicts. Journal of Consulting Psychology 1967; 31:536-538 69. Viederman M. Perry SW: Use of a psychodynamic life narrative in the treatment of depression in the physically ill. Gen Hosp Psychiatry 1980; 2:177-185 70. Dew MA, Ragni MY, Nirnorwicz P: Infection with human immunodeficiency virus and vulnerability to psychiatric distress. Arch Gen Psychiatry 1990; 47:737-744
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J. TREISMAN M.D., PH.D., CONSTANTINE G. LYKETsos, M.D. MARE FISHMAN, M.D., ANNETTE L. HANSON, M.D. ADAM ROSENBLATT, M.D., PAUL R. McHUGH, M.D.
This article reviews the literature on the classification and treatment ofpsychiatric morbidity associated with infection from the human immunodeficiency virus (HW). The psychiatric disorders seen in HW-infected patients are formulated by using one ofthe following four perspectives as treatment guides: J) the syndromal or disease perspective, 2) the dispositional or personality perspective. 3) the behavioral or addictive perspective, and 4) the life story perspective.
Received May I. 1992; revised June 5. 1992; accepted November 17. 1992. From The AIDS Psychiatry Service. Depanrnent of Psychiatry and Behavioral Sciences. The Johns Hopkins University School of Medicine. Address reprint requests to Dr. Treisman. The AIDS Psychiatry Service. Depanrnent of Psychiatry and Behavioral Sciences. Meyer 4-119.600 North Wolfe Street. Baltimore. MD 21287-7419. Copyright © 1993 The Academy of Psychosomatic Medicine. 432
PSYChiatriC care has become an integral part of the care of human immunodeficiency virus (HIV)-infected patients, especially given the substantial psychiatric morbidity encountered in this patient population. A variety of approaches to psychiatric evaluation, diagnosis, and treatment have been applied with varying degrees of success. A bibliography on psychiatric disorders and treatment in HIV-infected patients has been compiled recently.1 This article summarizes our experience in a general medical clinic caring for HIV-infected patients, both as providers of primary psychiatric care and as outpatient and inpatient consultants throughout the Johns Hopkins Hospital. Our approach is organized around the perspectives described by McHugh and Slavney,2 a series of methods that categorize the problems seen in psychiatric patients. Each perspective brings to the patient its own unique logic and set of priorities and directs treatment in a particular way. Depending on the problem, one or more of the perspectives may be more salient in formulating a particular treatment approach for a patient. Patients can be seen as having any combination of four different types of disorders: I) the syndromal or disease category in which disorders arise because of a "broken part" in their physiologic makeup; 2) the behavioral or addictive disorders in which problems arise when motivational drives go awry; 3) the PSYCHOSOMATICS
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dispositional or personality disorders, where difficulties emerge from an individual's temperament; and 4) disorders that stem from achange in a person's life circumstances and the individual's difficulties in coping with them. DISEASE AND SYNDROMAL DISORDERS Syndromally defined major mental illnesses are the first focus of our discussion. The high prevalence of these disorders that we discerned in our patients matches several published studies showing that individuals in the HIV high-risk categories suffer from an increased lifetime prevalence of major mental illness, especially major depression and anxiety disorders. In homosexual men who are uninfected or early in the course of mv infection, there is an increased lifetime prevalence of both affective disorders and anxiety disorders.3-S In clinics where drug abuse is the primary focus for treabnent, there is a 20%-30% comorbid diagnosis of affective disorder in the absence of mv infection as well as an increase in the rates of schizophrenia and other disorders6 (L. Cottier, personal communication, November 1991). Major Depression Depressed mood is the most common reason for psychiatric referral in our HIV medical clinic and elsewhere.7-14 It is a feature of many disorders, including major depression, grieving, and demoralization or adjusbnent disorder. Major depression is the most commonly diagnosed psychiatric disorder in several clinics. I 5-16 In HIV-infected patients, it appears in its classic form,I7 with severely depressed mood, anhedonia, hopelessness, helplessness, poor self-attitude, and attendant neurovegetative phenomena. It is difficult at times to decide whether vegetative signs stem from the depression or are a result of the HIV infection itself. Therefore, exclusive reliance on their presence to diagnose depression is not suggested. Rather, the clinician should look for accompanying "cognitive" symptoms of depression and changes in self-attitude. The most common neurovegetative features are diurnal mood variation, anorexia, weight loss, cognitive impairment, psychomotor retardation, impaired libido, and sleep disturbance with early morning awakening. We have seen an increased incidence of major depression late in the course of HIV infection, and the emergence of this syndrome is correlated with low CD4 counts and the development of AIDS. 16 Although the demoralization related to the awareness and progression of illness might be mistaken for major depression, the correct diagnosis is usually clear when these classic symptoms cluster into a full syndrome of major depression. These cases follow the typical natural history of the syndrome as well as the expected response to treabnent. VOLUME 34 • NUMBER S• SEPrEMBFR - OCTOBER 1993
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We have been impressed by the response to medications in this patient population and have seen an 85% response to treatment in our clinic, with a 50% complete recovery rate in patients treated with antidepressants. 16 We favor profile drugs that have low side effects, such as nortriptyline, desipramine, and fluoxetine, but we have had a good response in patients with most of the antidepressants we have used. In addition, we have needed to develop therapeutic plasma levels in patients to obtain a response and frequently need to try several drugs to get a profile of side effects that the patient can tolerate. Insomnia from fluoxetine has responded to low-dose trazodone (25-50 mg po qhs), and other side effects, such as dry mouth and constipation, decrease when increased fluid intake is encouraged. As has been reported elsewhere, we have found that the use of low-dose psychostimulants in some of the amotivational or apathetic states, or in the most refractory depressions, may be useful. Most important is the need to "start low and go slow" to minimize the increased number of side effects that patients may experience. In addition, we have treated several patients with lithium to "augment" the effects of antidepressants, achieving good success in those who previously had responded marginally to treatment. Several authors report similar results in patients who responded to a wide range of medications and electroconvulsive therapy. 18-23 Delirium. Dementia, and "Psychotic" Disorders Delirium is a common diagnosis in HIV-infected patients in both outpatient and inpatient settings.11.1 3.24-25 This disorder presents in a variety of ways and frequently mimics other psychiatric disorders. The primary distinguishing characteristics are a fluctuation in level of consciousness and symptoms (the so-called "waxing and waning" mental state) as well as a "clouding" of consciousness that interferes with attention. Although a complete discussion of this topic is beyond our scope, a full evaluation of delirium is in order because outcome is heavily influenced by a prompt, accurate diagnosis of the underlying cause. An EEG can be extremely useful in clari434
fying this diagnosis in difficult cases. Specific temporizing treatments with very low-dose neuroleptic agents (0.5-1 mg of haloperidol po, im, or iv qhs) may be helpful if control of delusions or hallucinations, and/or if behavioral management. is the goal. 24 Dementia is also a common diagnosis and presents with the typical manifestations of subcortical dementia with impairment of memory and attention, apathy. amotivation, and general cognitive decline. 9.26--46 Screening evaluations with the Mini-Mental State Exam and written or verbal "trailmaking" tests are fast and useful ones that can be used at the bedside. Although dementia usually is a prognostically grim sign, treatment with zidovudine (AZT) has been useful and has significantly altered the course of dementia. particularly if begun early.47 Psychotic disorders, such as schizophrenia, delusional disorder, and transient atypical episodes, are seen in HIV-infected patients.6.IO.12.48-54 Most are associated with substance use/abuse or withdrawal, although some appear indistinguishable from the disorders seen in non-HIV populations. Epidemiologic evidence suggests that the latter occur with frequencies similar to the general population and most clinical studies support this. ss-56 Treatment then is similar to that used in other settings, with antipsychotics, supportive psychotherapy, and rehabilitative efforts all being crucial elements. 3s,SI,S7-ss We have seen a rate of manic episodes almost 10 times that of the general population in patients with AIDS. Half of the cases are in patients with personal and family backgrounds of affective disorder. The other half are patients late in the course of progression of AIDS who have developed mild or moderate dementia and who do not have personal or family histories of affective disorder. S9 Several others report similar findings, which suggests "that mania may be a late-stage "neuropsychiatric"complication ofthe infection.4s .6O-{)2 Management consists mainly of high-potency antipsychotics such as haloperidol because lithium is generally too toxic at the levels needed to be effective. We have avoided carbarnazepine and valproic acid because they pose a significant risk of myelosuppression in imPSYCHOSOMATICS
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munocompromised patients already taking agents such as AZT. SUBSTANCE USE AND OTHER BEHAVIORAL DISORDERS Although several features of HIV-infected patients contribute to the development and maintenance ofbehavioral disorders, these disorders are perhaps best dealt with as primary diagnoses. 2 Nationally, roughly one-half of new diagnoses of AIDS are related in some way to substance abuse. and this is the most rapidly increasing problem in our clinic and also poses a risk factor for the disease.6.63-«J The major difference with the disease perspective is that the behavioral disorder itself is seen as the patient's major difficulty regardless of what led to its development. The behavioral disorder is not assumed to be the result of a "broken part" in the body as would be the case in a disease. What causes a behavioral disorder is different from what sustains it. Attention is directed at the elements of habit, such as hunger, drive, conditioning, reward, and relative salience, that sustain the disorder. This reasoning in tum directs the primary goal of treatment, which is to stop the behavior and then to deal with comorbid disease, personality vulnerability, and life story issues. Although we are currently unable to provide adequate treatment resources in our clinic, we have been most successful when patients were approached with an integrated treatment plan, formulated according to American Psychiatric Association recommendations. This approach has proven effective in the treatment of patients with addiction problems regardless of HIV statuS. 67 All providers are involved in formulating a plan and the patient is "won over" to cooperate in a series of psychotherapeutic sessions often involving our "confrontation with a smile" approach. Patients are shown gradually that they have lost control of their behavior and that they must stop the behavior to avoid facing serious consequences. They are further persuaded that, in their best interest, they must relinquish control to the treatment team and follow their recommendations for a period of time. VOLUME 34 • NUMBER 5 • SEPTEMBER - ocrOBER 1993
The treatment involves three phases: 1) detoxification, 2) monitored maintenance with preparation for relapse, and 3) elimination of contributing comorbidity. The first phase is to stop the behavior. We have used both inpatient and outpatient approaches in this phase. Treatment of withdrawal symptoms, support for acute intoxication, and encouragement are all necessary. The second treatment phase involves all members of the clinic and is aimed at providing encouragement to the patient during a difficult time, particularly during relapse. A therapeutic contract, frequent urine toxicology screens, and involvement of family and housing providers are useful in maintaining medication and treatment compliance. We also rely heavily on the use of community resources, such as Alcoholics Anonymous, Narcotics Anonymous, and a variety of support groups, to aid our patients. Last, we have found that frequent, brief visits to assess the patient's progress and to monitor drug/alcohol abstinence are of vital importance. The third treatment phase includes the diagnosis of comorbid conditions, such as depression, personality disorder, and medical illness, that predispose an individual to substance abuse. It may be necessary to directly prescribe changes in social networks. jobs, or living situations. As difficult as such changes may be, they are often necessary to remove the patient from highly conditional cues. We have found that treatment of substance abuse, paraphilia, and other behavioral disorders as primary diagnoses has led to a dramatic improvement in both psychiatric and physical outcome for many of our difficult cases. PERSONALITY VULNERABILITY AND TEMPERAMENT DISORDERS We have defined vulnerabilities in a person's personality as those that emerge when a patient's life circumstances change, ones that negatively affect a patient who is psychologically and/or temperamentally unprepared to deal with the change in circumstances. 2 Impulsiveness, overdramatization, poor recognition of future consequences of current behavior, and inability to tolerate discomfort or delay all contribute to risk 435
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factors for HIV infection. 68 Therefore, it is not surprising that we see a high incidence of personality vulnerability in our clinic patients. In severe cases, these vulnerabilities lead to a sustained effect on the patients' behavior, to the degree that they meet criteria for personality disorder, according to DSM-III-R criteria. We have seen all types of character disorder, but mainly we see patients with features described as histrionic, antisocial, and borderline. We approached treatment in much the same way shown to produce good results elsewhere. s8 ,64 This approach is threefold: I) develop a therapeutic plan, 2) provide psychotherapy, and 3) treat the comorbid conditions. Involvement ofthe entire treatment team to prevent "splitting," identification of target symptoms and behaviors, and placing firm limits with fixed consequences that are agreed on in advance all are mainstays of the therapeutic plan. Cognitive and supportive psychotherapy directed at identifying for patients their vulnerabilities and assets has been our most useful technique. We use our previously described confrontation approach to remind patients that tolerating discomfort and inconvenience may have far better consequences than acting out their impulses. Comorbid conditions have already been described as accompanying personality disorder diagnoses in general, such as anxiety disorders, mood disorders, and substance abuse disorders. The percentage of these disorders we have found in our clinic are similar to those reported in other settings,6S and we find that treatment of the comorbid conditions is essential for treatment success. Although, as expected, the rate of successful treatment (i.e., reduction of psychiatric symptoms, improved compliance, and less explosiveness in the clinic) of personality disorder in our clinic is lower than for other diagnoses, we have had striking case success with this approach. LIFE CIRCUMSTANCE AND SITUATION The final and perhaps most crucial issue to address regarding psychiatric care in this population pertains to life circumstances. Loss of 436
physical and cognitive ability, as well as the loss of friends and even certain freedoms, may contribute to the demoralization and grieving that commonly occurs in these patients. These issues have been elaborated on by Viederman and Perry69 in their discussion of the meaning of disease within the individual's life story. Although there are the obvious comparisons to be made with and lessons to be learned from other medical clinics, such as cancer and chronic renal failure, certain problems are unique to our patient population. The stigma of being homosexual or an intravenous drug abuser may antedate the infection and is further compounded by the presence of a highly stigmatizing disease. This places AIDS patients in the paradoxical situation of having a certain and increasing need for services while being most at risk for having these services denied. 29 ,7G-74 Surprisingly, in spite of the presence of these difficulties, most of our patients cope well with the discomforts of their disease. 7s-n Group and supportive psychotherapy is helpful to many patients78-81 and is provided to patients in need in our clinic with good results. A complicating factor in distressed patients is the distinction between depression and demoralization. Patients face the "Damoclean" reality of living with the terminal uncertainties of HIV infection in the prime of life and endure progressive loss of the ability to function. Also, they suffer the need to depend increasingly on others for basic daily activities and are the victims of countless explicit and implicit prejudicial societal attitudes and the discriminatory practices of some institutions. In light of this, we have frequently jumped to the explanation that our patients are depressed because of the change in their life circumstances. It was not until we saw the good response rates mentioned in the frrst section of our discussion that we became more aggressive in the use ofmedications. These results differ from the experience in treating oncology and chronic renal failure patients in that we see a much higher rate of response to medication in mY-infected patients. 82--M While remaining empathetic, we have had to be careful not to be convey a "too understanding" attitude that might convey that depressive symptoms are an inevitaPSYCHOSOMATICS
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ble consequences of a tragic change in life circumstances rather than manifestations of a treatable affective disease. Therefore, we use careful diagnostic evaluation, close follow-up, and provide psychotherapy, as well as medication in those patients of unclear diagnosis. The more clearly demoralized patients usually respond well to psychotherapy. An approach to therapy similar to that already well described by other authors for other chronic diseases and HIV infection can be used to significantly improve both medication/treatment compliance and the quality of life for HIV-infected individuals. 69•78-80 CONCLUSION Our experience in caring for HIV-infected patients with psychiatric morbidity mandates careful diagnosis and formulation prior to initiation of treatment. One of the difficulties in managing complex patients with multiple problems is that
each new case tends to appear as a unique set. or tangle, of signs and symptoms. The use of several perspectives in formulating each patient approach 2 has improved our ability to organize treatment. By differentiating disorders using these perspectives. we have been able to identify recurring clinical patterns that encompass our patients' complicated and often chaotic problems. Careful evaluation for the presence of diseases, behavioral disorders, disorders of temperament, and disorders related to life circumstance has allowed us to make diagnoses, target treatments, and test hypotheses according to familiar principles. As a result. our patients' disorders have improved as have their compliance with medical treatment and their overall quality of life. Finally, recognition of these perspectives and their application to clinical care settings promotes the development of coherent research strategies in consultation-liaison psychiatry.
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