PSYCHIATRIC MANIFESTATIONS OF HIV/AIDS Presenter – Dr. D. Raj Kiran Chairperson – Dr. Supriya HegdeHIV does not make people dangerous to know, so you can shake their hands and give them a hug: Heaven knows they need it - Princess Diana
INTRODUCTION • HIV: A retrovirus, previously called the human T-cell lymphotropic virus (HTLV). This virus infects cells important for the human immune response, especially helper T cells, and leaves its host vulnerable to opportunistic infections. • AIDS: A clinical syndrome defined by HIV infection with certain associated signs and / or symptoms, known as AIDS-defining conditions
HISTORY • One of the earliest documented HIV infections was discovered in a preserved blood sample taken in 1959 from a man from Belgian Congo. • In 1981 the AIDS epidemic was first described in the medical literature, it was in 1983 that the first articles were published about the psychosocial or psychiatric aspects of AIDS by Holtz & colleagues. • First psychiatrist to address these issues was Stuart E. Nichols in his article in Psychosomatics.
HIV IN INDIA • It is estimated that India had approx 1.2 lakh new HIV infections in 2009 (2.7 lakh in 2000). • The estimated adult HIV prevalence in India was 0.31% in 2009. • The adult prevalence is 0.25% among women and 0.36% among men in 2009. • Manipur has shown the highest estimated adult HIV prevalence (1.40%) < Andhra Pradesh (0.90%) < Mizoram (0.81%) < Nagaland (0.78%) < Karnataka (0.63%) and Maharashtra (0.55%). http://www.nacoonline.org/upload/REPORTS/NACO%20Annual%20Report%202010-11.pdf
PATHOGENESIS OF NEUROPSYCHIATRICMANIFESTATIONS • One of the mechanisms is ―TROJAN HORSE HYPOTHESIS‖. • HIV-1 enters the brain inside infected macrophages. • These migrate into the brain parenchyma through BBB disruption and establishment of a chemokine gradient. • Virus buds into intra cytoplasmic vesicles in macrophages with limited expression of viral proteins on the cell surface and escapes from immune surveillance.
HIV TESTING IN INDIA • Testing for HIV requires specific and informed consent of the person being tested. • The confidentiality of the test result (both negative as well as positive) should be strictly maintained. • This is to respect the privacy and rights of the individuals and to protect them from discrimination, victimization and stigmatization. • The test result, name of the individual, etc. must never be discussed loosely. • The test report must be placed in a sealed envelope and submitted to the clinician who requisitioned the test. http://nacoonline.org/upload/Policies%20&%20Guidelines/5- GUILDELINES%20FOR%20HIV%20TESTING.pdf
PRE TEST COUNSELING • Information about the HIV test - what it tests for, what it might NOT tell (window period). • Information about how HIV is transmitted and how patient can protect from infection. • Information about the confidentiality of test results. • A clear, easy-to-understand explanation of meaning of a positive and a negative test. http://aids.gov/hiv-aids-basics/prevention/hiv-testing/pre-post-test-counseling/
POST TEST COUNSELING • Clear communication about what the test result mean. • If test is negative - HIV prevention counselling. • If test is positive - A confirmatory test, Western blot test. The results of that test should be available within 2 weeks. • If confirmatory test is positive, then - Patient will be given information about what HIV is & how it effects health. Patient will be informed about how the virus can affect & how to protect others from becoming infected. Patient will also be informed about resources & treatments available. http://aids.gov/hiv-aids-basics/prevention/hiv-testing/pre-post-test-counseling
MANIFESTATIONS OF HIV INFECTION (i) Malignant course of HIV infection and the associated stigma. (ii) Direct effects of HIV on brain. 1. Delirium 2. Mild cognitive and motor disorders 3. Dementia (iii) Vulnerability of Persons with severe mental illness to HIV infection. 1. Mood disorders 2. Psychosis 3. PTSD 4. Personality disorders 5. Anxiety and phobic disorders 6. Adjustment disorders
STIGMA ATTACHED WITH HIV INFECTION • HIV/AIDS stigma is perceived as an individual‘s deviance from socially accepted standards of normality and can include such deviances as ‗‗immorality, promiscuity, perversion, contagiousness and death ‘‘. • Stigma is socially constructed and is attributable to cultural, social, historical and situational factors. • Stigmatised individuals are subject to ‗‗feelings of shame and guilt‘‘. • Women are more vulnerable to the stigma.
STIGMA • There are three broad types of HIV/AIDS-related stigma. 1. Self stigma - occurs through ‗self blame and self- deprecation‘. 2. Perceived stigma - related to the fear that individuals have that if they disclose their HIV positive status 3. Enacted stigma - occurs when individuals are actively discriminated against because of their HIV status. • The cause of HIV/AIDS stigma is Ignorance, Lack of accurate information about HIV/AIDS & Misunderstanding about HIV transmission
STIGMA • Joining the support groups will help in decreasing stigma by 1. Providing more knowledge about the illness. 2. How to deal with it. 3. Get to know more about others who are in the same situation as themselves. 4. Joining the group makes them realise that they are not alone in the lonely world of life with HIV/AIDS. • Support groups for AIDS in INDIA – SAATHII (Solidarity and Action Against The HIV Infection in India) - Chennai, ASHA Foundation - Bangalore, THE HUMSAFAR TRUST - Mumbai, Indian Network for People Living with HIV/AIDS(INP+) - Chennai, Save the Children, Bal Raksha, Bharat - Delhi.
DELIRIUM • It is a state of global derangement of cerebral function. • Prevalence is reported to be between 43 – 65%. • The clinical presentation in HIV patients is the same as those in non-HIV-infected individuals. • Patients with HIV associated dementia are at increased risk of developing Delirium. • In toxic/ metabolic causes, the EEG may show diffuse slowing of the background alpha rhythm, which resolves as confusion clears.
DELIRIUM • The cause of delirium should be aggressively sought by intensive medical examination. • Treatment 1. Identification & removal of underlying cause. 2. Reorientation of the patient by maintaining diurnal variation of light cycle, providing orienting stimuli such as clocks, calendars & active engagement of family members. 3. Management of behavior/psychosis by low dose of high potency antipsychotic.
MINOR COGNITIVE MOTOR DISORDER • It is a less severe neurocognitive disorder emergent in earlier HIV infection. • Prevalence data are variable, often up to 60% by late- stage AIDS. • The symptoms are subtle & mild manifestations of the same symptoms seen in HIV-associated dementia: Cognitive and motor slowing.
MINOR COGNITIVE MOTOR DISORDER • The disorder is confirmed when mild impairments are present in at least two of the following domains: Verbal/language, attention, memory (recall or new learning), abstraction, and motor skills. • HAART may be of some benefit in slowing progression. • Some patients may continue to have minor problems, while another group will progress to frank dementia.
HIV ASSOCIATED DEMENTIA • Prevalence of HIV dementia in infected adult is reported to be 15%. • It is generally seen in late stages of HIV illness, usually when CD4+ count is below 200 cells per ml. • Risk factors associated are higher HIV RNA viral load, lower educational level, older age, anaemia, illicit drug use & female sex. • HIV itself is the causative factor, it acts through activation of cytokines and chemokines that trigger abnormal neuronal pruning.
HIV ASSOCIATED DEMENTIA • Apathy is a common early symptom of HIV-associated dementia. • Clinically presents with triad of symptoms - memory and psychomotor speed impairments, depressive symptoms, and movement disorders. • Early cases show impairments in timed trials such as a timed oral trail making task or grooved pegboard, occasional stumbling while walking or running, slowing of fine repetitive movements.
HIV ASSOCIATED DEMENTIA • Modified HIV Dementia Scale is a useful bedside screen & for disease progression. • In late stages patients develop more global dementia, with marked impairments in naming, language, praxis, marked difficulty in smooth limb movements. • Overall, HIV-associated dementia is rapidly progressive usually ending in death within two years. • Treatment is to ensure an optimal HAART regimen and treat associated symptoms aggressively.
DEPRESSION • Most frequently occurring psychiatric disorder in HIV. • Lifetime prevalence in HIV infected patients is 22–45%. • The Multi centre AIDS Cohort Study (MACS) showed that there is a two & half fold increase in rates of depression as patient CD4 < 200. • Up to 15–20% of all patients with recurrent depressive episodes end up in suicide.Vinita Jagannath, B. Unnikrishnan, Supriya Hegde, John T. Ramapuram, S.Rao, B. Achappa, D.Madi, M.S. Kotian. Association of depression with social support and self-esteem among HIVpositives. Asian J Psy 2011:4, 288-292.
DEPRESSION ↔ HIV • Depression is a risk factor for HIV - impact on behaviour, intensification of substance abuse, exacerbation of self-destructive behaviours & promotion of poor partner choice in relationships. • HIV increases the risk of developing major depression - direct injury to subcortical areas of brain, chronic stress, social isolation, intense demoralization, HIV related medical conditions & medications.
Depression ↓ Increase in Cortisol levels ↓ Decrease in circulating lymphocytesReduce the ability of lymphocytes to produce lymphokines Increase expression of HIV by Mononuclear cells
DEPRESSION • Nonspecific somatic symptoms (fatigue, insomnia) are the result of depression. • Drugs causing depression → withdrawal of the offending drug, if no response then treated as major depression. • Medication plus psychotherapy (Interpersonal & CBT) - more effective than either modality alone.
DEPRESSION • No single antidepressant has been found superior. • SSRIs 1st choice, then TCAs. • Start at low doses of any medication, titrate up to a ―full‖ dose slowly. • Partial response to antidepressant medication should be offered an augmentation strategy (Li, Triiodothyronine, Olanzapine, Risperidone).
SUICIDE & HIV INFECTION • 16 – 17 times higher than general population. • Accounts for 0.8% of all AIDS death. • Risk factors include – Inadequate pre & post test counseling, manner in which news revealed, emotional support. Stage of disease. Psychosocial factors – stress, isolation, denial, drug abuse, social support.
SUICIDE & HIV INFECTION • Risk assessment. • Treatment of underlying depression. • Treatment of physical complaints. • Crisis intervention. • Supportive therapy or CBT.
BIPOLAR ILLNESS • Difficult to find out the incidence & prevalence of bipolar illness among HIV because the spectrum of bipolar illness is broad. • Bipolar disorder act as a risk factor.
AIDS MANIA • Associated with late-stage HIV infection. • Consequences of brain involvement. • Progressive cognitive decline prior to the onset of mania. • Irritable mood is more characteristic than euphoria. • Psychomotor slowing with cognitive slowing of AIDS dementia will replace the expected hyperactivity of mania • Lack of previous episodes or family history. • Has chronic course rather than episodic.
BIPOLAR ILLNESS • Treatment of mania in early stage HIV infection is same as that for the standard treatment of bipolar disorder. • Mood-stabilizing medications, particularly Lithium salts, Valproic acid, Lamotrigine, Carbamazepine and Antipsychotic agents. • AIDS mania patients typically respond to treatment with antipsychotic agents alone.
BIPOLAR ILLNESS • Lithium – problematic because Delirium, GI side effects, Cognitive difficulties, Polyurea → Dehydration, DI, rapid fluctuations in blood levels. • Valproic acid – hepato toxic, alters hematopoietic function. • Carbamezapine – sedation, bone marrow suppression synergistic to HAART.
SCHIZOPHRENIA • Prevalence rates of 4 - 19%. • No evidence about HIV infection causes schizophrenia. • There are data to show that schizophrenia contributes to behaviours that may lead to HIV infection. • Patients with more positive symptoms & impulse control problems are at increased risk for high-risk sexual behaviour. • Disease generally tend to be more serious in patients with schizophrenia.
SCHIZOPHRENIA • Treatment follows same basic principles as any other patient with schizophrenia, namely control of symptoms with medications, psychosocial support & rehabilitation. • Numerous reports suggest that HIV-infected patients may be vulnerable to extrapyramidal symptoms, including neuroleptic malignant syndrome and tardive dyskinesia. • So it is recommended that low doses of high potency neuroleptics to be used. • Avoid Efavirenz -based regimens due to a higher risk of neuro psychiatric side effects.
PTSD • It engender or exacerbate HIV risk behaviors and worsen health outcomes. • Symptoms of PTSD are associated with risk behaviors and markers of HIV progression. • In HIV treatment, traumatic stressors and PTSD symptoms have been associated with a lower CD4 T cell to CD8 T cell ratio at 1 yr follow-up. • PTSD is most often comorbid with depression and substance abuse—both risk factors for HIV
PTSD • Instruments used for screening for PTSD are Trauma History Questionnaire & the PTSD Checklist. • Treatment typically involves behavioural exposure and flooding. • Treatment should address coexisting depression or substance abuse or it may worsen psychiatric status.
PERSONALITY DISORDERS • Prevalence rates of personality disorders among HIV at risk is 15 - 20%. • High-risk behaviours among individuals who are HIV- infected. • Traditional approaches in risk reduction counselling emphasize the avoidance of negative consequences in the future. • Such approaches have proved ineffective for individuals with certain personality characteristics.
PERSONALITY DISORDERS • No specific ―alcoholic‖ or ―drug-using‖ personality. • Link between substance abuse & either impulsivity/high novelty seeking or high on neuroticism/negative emotionality. • Individuals with both these traits may be at the greatest risk of addiction. • In the Psychiatry Service of the Johns Hopkins AIDS Service (JHAS), about 60% of patients present with the blend of extroversion & emotional instability.
PERSONALITY DISORDERS • Antisocial personality disorder is the most common and is a risk factor for HIV infection. • High rates of substance abuse, more likely to inject drugs & share needles, higher numbers of lifetime sexual partners, engage in unprotected anal sex & contract STDs.
PERSONALITY DISORDERS • Personality traits were not directly related to HAART adherence. • Non adherence is more common among extroverted or unstable patients. • The personality characteristics that are associated with risk for HIV also reduce the ability to adhere to drug regimens. • A cognitive-behavioural approach is most effective in patients with extroverted and/or emotionally unstable personalities.
AIDS PHOBIA • It is the fear of contracting HIV infection, despite the negative test results. • In addition to distinct AIDS related fears, somatization disorders have been reported among men with risky behaviour who tested negative for HIV. • They have been associated with an anxious temperament, are more among those with health anxiety. • Often associated with misinformation and inadequate knowledge. • Treatment – Psychotherapy & Antidepressants.
SUBSTANCE ABUSE • Substance abuse is a primary vector for the spread of HIV. • Often demoralized, become hopeless & are more likely to engage in high risk behaviours. • Patients with substance use disorders may not seek health care or may be excluded from health care. • Addiction and high-risk sexual behaviour have been linked across a wide range of settings.
SUBSTANCE ABUSE • The accumulation of medical sequale from chronic substance abuse can accelerate the process of immunocompromise & amplify the progressive burdens of the HIV infection itself. • They become vulnerable to pneumonia, sepsis, soft tissue infections, endocarditis, tuberculosis, STDs, viral hepatitis infection & coinfection with human CD4 cell lymphotrophic virus, lymphomas. • Neurological symptoms can overlap between HIV infection and substance abuse.
SUBSTANCE ABUSE • Dual diagnosis - refers to a patient who has both a drug use disorder and another psychiatric disorder. • Triple diagnosis - refers to a dual diagnosis patient who also has HIV. • The steps for the treatment of substance in a simple way - 1. Role induction & motivation to change 2. Detoxification 3. Treatment of co-morbid conditions 4. Rehabilitation 5. Relapse prevention
OPPORTUNISTIC INFECTIONS Toxoplasmosis: • When CD4 < 200 cells per microliter. • most common reason for intracranial masses. • Ring-enhancing lesions in the basal ganglia or at the gray–white matter junction. • Acute focal or diffuse meningoencephalitis - headache, fever, altered consciousness and focal neurological signs.
OPPORTUNISTIC INFECTIONS Cytomegalovirus: • CD4 < 50 cells per microliter. • Two distinct syndromes of CMV CNS infection. Encephalitis with dementia subacute onset, periods of delirium, confusion, apathy & focal neurological deficits. Ventriculoencephalitis infects the ependymal cells, causing a rapid progression from delirium to death. • Treatment supportive, gancyclovir, foscarnet
OPPORTUNISTIC INFECTIONS Cryptococal meningitis: • 8 -10%. • Present with fever and delirium. • Treatment amphotericin B and flucytosine. Progressive multifocal leukoencephalopathy: • Demyelinating disease of white matter. • Polyoma virus, named JC virus. • CD4 < 100 cells per ml. • Treatment supportive , HAART
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