Psychological Features of Illness and Recovery Patterns in HIV Disease PHASE, Canadian Psychological

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Psychological Features of Illness and Recovery
Patterns in HIV Disease PHASE, Canadian
Psychological Association and Health
CanadaModule Developed by Paul C. Veilleux,
Ph.D. UHRESS - Centre Hospitalier de
lUniversité de MontréalMontreal, Quebec
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Aids

• The fourth stage of HIV infection, diagnosed when
  serious opportunistic disease or a CD4 cell count
  of less than 200 occurs, is commonly referred to
  as AIDS. Treatment at this stage includes both
  continuation or enhancement of antiretroviral
  therapy and the prophylaxis, diagnosis and
  treatment of specific opportunistic diseases as
  they occur.

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Common HIV-Related Opportunistic Infections

• CD4 gt 500
• Lymphadenopathy
• Recurrent vaginal candidiasis

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Common HIV-Related Opportunistic Infections

• CD4 200 - 500
• Pneumoccocal pneumonia
• Pulmonary tuberculosis
• Herpes
• Oral candidiasis

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Common HIV-Related Opportunistic Infections

• CD4 200 - 500
• Cervical neoplasia
• Anemia
• Kaposis sarcoma
• Non-Hodgkins lymphoma

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Common HIV-Related Opportunistic Infections

• CD4 lt 200
• Pneumocystis carinii pneumonia (PCP)
• Mycobacterium avium intracellulare (MAI)
• Cytomegalovirus (CMV- retinitis)
• Lymphoma

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Common HIV-Related Opportunistic Infections

• CD4 lt 200
• Toxoplasmosis
• Progressive multifocal leukoencephalopathy
  (PML)
• AIDS dementia complex

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Neuropsychological and Neuropsychiatric Effects
of Medications Used in HIV Disease

• AZT (antiretroviral)

• Headache, feeling ill, asthenia, insomnia,
  unusually vivid dreams, restlessness, severe
  agitation, mania, auditory hallucinations,
  confusion
• Headache, asthenia, feeling ill, confusion,
  depression, seizures, excitability, anxiety,
  mania, early awakening, insomnia

• d4T (antiretroviral)

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Neuropsychological and Neuropsychiatric Effects
of Medications Used in HIV Disease

• Ddc (antiretroviral)

• Headache, confusion, impaired concentration,
  somnolence, asthenia, depression, seizures,
  peripheral neuropathy
• Nervousness, anxiety, confusion, seizures,
  insomnia, peripheral neuropathy, pain
• Insomnia, mania

• ddI (antiretroviral)

• 3TC (antiretrovirale)

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Neuropsychological and Neuropsychiatric Effects
of Medications Used in HIV Disease

• Acyclovir (herpes encephalitis)

• Visual hallucinations, depersonalization,
  tearfulness, confusion, hyperesthesia, thought
  insertion, insomnia
• Delirium, peripheral neuropathy, diplopia
• Paresthesias, seizures, headache, irritability,
  hallucinations, confusion

• Amphotericin B (cryptococcosis)

• Foscarnet (Cytomegalovirus)

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Neuropsychological and Neuropsychiatric Effects
of Medications Used in HIV Disease

• Confusion, paranoia, hallucinations, mania, coma
• Depression, loss of appetite, insomnia, apathy
• Psychosis, somnolence, depression, confusion,
  tremor, vertigo, paresis, seizures, dysathria

• B-lactam antibiotics (infections)

• Co-trimoxazole (PCP)

• Cycloserine (tuberculosis)

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Neuropsychological and Neuropsychiatric Effects
of Medications Used in HIV Disease

• Interferon (Kaposis sarcoma)

• Depression, weakness, headache, myalgias,
  confusion
• Confusion, anxiety, lability, hallucinations
• etc.

• Pentamidine (PCP)

• etc.

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Events That May Trigger Crises

• HIV testing
• HIV diagnosis
• Fear of disclosure
• Viral load T4 count
• Concerns about negotiating safer sex and/or
  needle use
• First opportunistic infection

• First hospitalization
• Treatment failure
• Leaving ones job
• Moving into a hospice
• Confronting losses
• Anticipating death
• etc.

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Losses and Transformations Facing Persons Living
with HIV/Aids

• Physical capacities
• Mental faculties
• Body image, dignity
• Income, Job, status
• Independence, Ano-nymity
• Mobility, Recreation

• Family, friends
• Love and intimacy
• Sense of self and ones role in the world
• Anticipation, Control over the future
• Sense of invulnerabil-ity and immortality

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Major Stressors Facing Persons Living with
HIV/Aids

• Job loss, financial insecurity and medical
  expenses
• Informing others about the diagnosis
• Fear of loss of body functions and/or of physical
  disability
• Fear of loss of mental functions and autonomy
• Changes in body image and self-image

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Major Stressors Facing Persons Living with
HIV/Aids

• Loss of control over one's life
• Loss of ones home
• Apprehension of social isolation as death
  approaches

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Managing Chronic Health Problems

• Assessing anxiety, depression, neuropsychological
  symptoms, and the need for intervention
• Organizing support services
• Educating and organizing family, friends, and
  partners about one's changing needs

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Managing Chronic Health Problems

• Learning to set flexible goals to accommodate
  changes in energy and health status
• Weighing medical treatment needs against quality
  of life issues
• Dealing with anticipatory grief in self and
  others
• Determining what is worth the effort and what is
  not

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Processes related to getting well again (new
antiretroviral therapy)
Multiples losses Deinvestment
Reinvestment or deinvestment ?
Ambivalence
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Reinvestment?

• Intimate relationships
• Social involvement
• Desire to have a child
• Return to work
• Return to school
• etc.
• For how long ???

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Returning to Work Positive Consequences

• Quality of life
• Self-confidence
• Personal and social self-actualization
• Economic status
• Independence

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Returning to Work Negative Consequences

• Anxiety
• Medication (cost, side effects, regimen)
• Difficulty finding a place in the job market
• Confronting the social network
• Lost of benefits (insurance, long-term disability
  plan, etc.)
• Uncertainty about how long one will stay working

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Returning to Work Psychological and Social
Consequences

• Consult and inform yourself about the
  consequences
• Medical
• Financial
• Social
• Psychological
• Make an enlightened decision.

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Grief Issues in Therapy

• You can't fix grief whats lost is lost.
• Allow depression and sadness don't try to take
  them away.
• Sit with the client and witness the tough
  feelings.
• It's hard to be helpless both for the client
  and for the therapist.

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Grief Issues in Therapy

• Just listening is often the best intervention
  sometimes you don't have to do or say anything.
• Continually give clients permission and
  encouragement to grieve.
• Clients feel safest to grieve when they know
  their grief can be expressed and contained.

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Facilitating the Grief Process

• Actualize the loss through talking and rituals.
• Encourage the expression of feelings.
• Assist in developing skills for living without
  the deceased.
• Facilitate emotional removal.

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Facilitating the Grief Process

• Encourage specific times for grieving.
• Normalize grieving behaviour.
• Allow for individual and cultural differences in
  grieving.
• Identify non-productive coping and pathological
  grieving.

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Case Study Instructions for Participants

• Form discussion groups of about five
  participants. Choose a case example that you
  wish to discuss and answer the four questions
  shown. Name a spokesperson who will give a
  summary of your responses or ideas. You will have
  approximately 30 minutes to discuss and then you
  will share your ideas with the rest of the class.

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Case Study Questions

• Read the case examples, choose one case, and
  answer the following questions
• 1. What are the feelings and emotions of the
  patient or client?
• 2. What are your feelings and emotions regarding
  this person and situation?
• 3. What are the needs of the patient or client?
• 4. What solutions or strategies would you
  suggest?

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Marie

• Marie has known that she is HIV for seven
  years. She is hospitalized for the first time
  with a PCP. The physician also discovered a
  lymphoma for which she will receive chemotherapy.
  She is exhausted because she had kept on working
  until this hospitalization. She is a single
  mother of a 5-year-old son named Antoine. He is
  HIV-. Marie's mother is taking care of him during
  the hospitalization. Marie has never told Antoine
  about her seropositivity or illness. She is
  anxious to tell him about her health problems and
  doesn't know how to do it. She is afraid that she
  might have to quit her job. She is also afraid of
  dying. She feels in a panic. You are called on to
  help her.

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John

• John is a young IDU. He is a prostitute. He has
  experienced periods of incarceration because of
  his work. He is well known by the emergency room
  staff. Some members of the team have pity for him
  while others are hostile toward him. He is
  presently hospitalized for a skin problem related
  to his drug use. He has also a PCP. He should be
  hospitalized for two weeks. After a few days, he
  receives his welfare cheque and asks for a few
  hours leave. The staff is concerned because this
  type of client frequently does not come back. The
  staff requires your help in this situation.

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Claire

• Claire is a 30-year-old black woman from the
  Caribbean. Her husband died two years ago from
  AIDS. She was expecting herself to die in the
  year following her husbands death since her CD4
  count was below 50 and she had had several
  opportunistic infections. She spent almost all
  her savings and is now receiving welfare. With
  the new treatment, her CD4 count is up to 200 and
  she has an undetectable viral load. She is afraid
  of going on with her life (maybe meeting someone
  else, having a baby, getting a job) because she
  feels that it would be a betrayal of her husband.
  She is asking for help.

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Jacques

• Jacques is André's lover. André has been at the
  AIDS stage for two years Jacques is
  HIV-negative. They have been living together for
  the last 12 years. Jacques, a high school
  teacher, is responsible for the housekeeping and
  André's medical visits, etc. André is blind as a
  result of CMV retinitis. Jacques expected André
  to die in the last year but with the new
  treatment André is still alive. He comes to you
  because he is exhausted from taking care of
  André, and he feels guilty when he thinks that
  André's death would be an easy solution to his
  problem. He ask for help.

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Peter

• You have been following Peter in psychotherapy
  for almost two years. In the past six months, he
  has been receiving treatment for CMV retinitis.
  He has lost his sight in his right eye and his
  left eye is affected. On a cloudy day, he comes
  to your office. You notice that his vision is
  worse because he has to feel with his hands for
  where objects are. Peter is proud and strongly
  values. With tears in his eyes, he says he would
  prefer death to blindness. How can you help him ?

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Exercise Daily Medication Schedule

• Choose a sample daily medication schedule that a
  person with HIV may be taking (examples follows).
  Using yourself and your typical daily schedule
  (at work, home, or here today), map out your
  days medication regimen, integrating it with
  meals and other daily activities.

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Exercise Daily Medication ScheduleQuestions for
Small Group Discussion

• What are some possible challenges to following
  your medication schedule?
• What are your emotional reactions to this
  schedule?
• How likely would you be to follow your schedule
  as instructed?

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Exercise Daily Medication ScheduleQuestions for
Small Group Discussion

• How would you follow your schedule if you
• were visually impaired ?
• were depressed ?
• were homeless ?
• didnt want anyone to know you were HIV ?
• were cognitively impaired ?
• What could help you to better follow your
  medication schedule ?

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Exercise Daily Medication Schedule Example 1

• AZT three pills (3X100mg) two times a day taken
  with food
• 3TC one pill (150 mg) twice a day, can be taken
  with food
• Crixivan two pills (2X400mg) every 8 hours
  around the clock, with water, skim milk, juice,
  coffee, or tea one hour before or two hours
  after a meal drink a minimum of 1.5 litres
  (preferably water) throughout the day, store at
  room temperature, keep dry

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Exercise Daily Medication Schedule Example 2

• Nelfinavir five pills (5x250mg) twice a day,
  with a meal
• Saquinavir five pills (5X200mg) twice a day,
  with a meal
• ddI two pills (2x100mg) twice a day, 30 minutes
  before or 2 hours after meals
• d4T one pill (40mg) twice a day can be taken
  with food

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Exercise Daily Medication Schedule Example 3

• Indinavir two pills (2x400mg) twice a day with a
  meal
• Ritonavir 5ml 400mg twice a day tastes awful
• ddI two pills (2x100mg) twice a day must be
  taken one hour before or after the indinavir and
  the ritonavir
• Hydoxyurie one pill (500mg) twice a day can be
  taken with food
• Septra one pill (5mg) once a day, without food
  if possible

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Psychosocial Issues Around AIDS and Late
HIV-Disease

• Coping with life as a person with AIDS
• Managing chronic health problems
• Time issues and life issues
• Preparing to die

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The Psychologists Role in Medical Treatment

• Explore how symptoms, diagnostic procedures,
  medications and treatment procedures affect daily
  living and ones sense of self.
• Assist the client in formulating questions for
  his or her physician.
• Offer emotional support and suggest ways of
  establishing a sense of control whenever possible.

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The Psychologists Role in Medical Treatment

• Teach relaxation and pain management techniques.
• Educate clients and significant others about
  neuropsychological complications and strategies
  for managing them.

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Psychotherapeutic Framework

• Client-centred
• Team approach
• Flexibility (acknowledge ignorance)
• System negotiation
• Constant interplay between management and meaning

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Maintaining Boundaries and Avoiding Burnout

• Tell clients how often, where and when you will
  see them. Tell them early on in the therapeutic
  relationship.
• Continually review the new commitments you make
  in light of how many HIV-infected clients you are
  seeing at various stages of the disease.

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Maintaining Boundaries and Avoiding Burnout

• Anticipate the emerging needs of clients and
  assess services before those needs become
  desperate.
• Know the resources in your community and how to
  use them.

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