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HIV AND PSYCHIATRIC ILLNESS

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HIV AND PSYCHIATRIC ILLNESS Karina K. Uldall, MD, MPH Department of Psychiatry HIV/AIDS Research Program University of Washington – PowerPoint PPT presentation

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Title: HIV AND PSYCHIATRIC ILLNESS


1
HIV AND PSYCHIATRIC ILLNESS
  • Karina K. Uldall, MD, MPH
  • Department of Psychiatry
  • HIV/AIDS Research Program
  • University of Washington

2
OVERVIEW
  • AIDS Defining Neurological Illnesses
  • Other CNS Disorders
  • Psychiatric Illness in HIV/AIDS
  • Diagnosis and Treatment

3
AIDS DEFINING NEUROLOGICAL ILLNESS
  • CMV Encephalitis
  • Progressive Multifocal Leukoencephalopathy (PML)
  • Toxoplasma Encephalitis
  • Primary CNS Lymphoma
  • Cryptococcal Meningitis
  • Rarely TB Meningitis and Kaposis Sarcoma

4
CMV ENCEPHALITIS
  • Disorientation, confusion, apathy
  • Psychomotor retardation, lethargy, cranial nerve
    abnormalities
  • Abrupt onset, short course
  • CD4 count lt 50/uL
  • Diagnosed via CSF PCR
  • Treated with foscarnet, ganciclovir, both
  • Survival less than 2 months

5
PROGRESSIVE MULTIFOCAL LEUKOENCEPHALOPATHY
  • Occurs in approximately 4 of patients
  • Focal weakness, visual loss
  • 10 spontaneously improve
  • CD4 count lt 100/uL
  • Diagnosed via CSF JC virus PCR
  • No clear treatment
  • Survival 1 to 4 months

6
TOXOPLASMA ENCEPHALITIS
  • Approximately 10 of HIV patients, most common
    CNS mass in AIDS (60)
  • Activation of previous infection
  • Fever, headache, weakness, visual symptoms,
    seizures, cognitive changes
  • CD4 count lt 200/uL
  • Contrast scan - multiple enhancing lesions, basal
    ganglia, gray-white junction
  • Treated with pyrimethamine/sulfadiazine

7
PRIMARY CNS LYMPHOMA
  • Approximately 3-5 of HIV patients
  • Second most common CNS mass in AIDS
  • Presentation depends on location of tumor
  • CD4 count lt 100/uL
  • Contrast scan - usually single lesion noted
  • Treated with radiation
  • Survival 2 to 6 months

8
CRYPTOCOCCAL MENINGITIS
  • Occurs in approximately 7 of HIV patients
  • Fever, headache, cognitive changes
  • Insidious onset spanning 2 to 4 weeks
  • CD4 count lt 100/uL
  • Diagnosed via CSF culture, India ink stain
  • Treated with amphotericin B and fluconazole

9
OTHER CNS DISORDERS
  • Bacterial/Viral Meningitis
  • Neurosyphilis
  • Herpes Simplex Encephalitis
  • Varicella-Zoster Encephalitis
  • Rarely Histoplasmosis and Coccidiodomycosis

10
PSYCHIATRIC ILLNESS IN HIV/AIDS
  • HIV Associated Dementia (HAD)
  • Delirium
  • Psychotic Disorders
  • Mood Disorders
  • Anxiety Disorders
  • Substance Abuse and Dependence

11
HIV ASSOCIATED DEMENTIA
  • 15-20 of AIDS patients
  • Combination of motor, cognitive and
    mood/personality changes
  • Insidious onset, CD4 count lt 200/ul
  • CSF Beta-2-microglobulin gt 3.8 mg/dL, HIV-1 RNA
    gt10,000/ml
  • AZT, AZT3TC, d4T3TC, Indinavir

12
DELIRIUM
  • Disturbance of consciousness with attention
    problems
  • Change in cognition or development of a
    perceptual disturbance
  • Acute onset with fluctuating course
  • Underlying etiology
  • fever/infection, trauma, metabolic, meds/drugs,
    other cause(s)

13
DELIRIUM
  • Common in later stages of disease, 30-60 of
    patients
  • Often confused with dementia and depression
  • Associated with poor outcomes - mortality, long
    term care, longer hospitalization
  • Treatment of choice is haloperidol unless
    etiology is alcohol/benzodiazepine withdrawal

14
PSYCHOTIC DISORDERS
  • Substance induced during intoxication or
    withdrawal
  • Medical illness induced
  • must be distinguished from delirium
  • late stage HIV associated dementia

15
MOOD DISORDERS
  • Bipolar disorder - 8 of outpatients
  • Major depressive episode
  • 6-10 current and 20-35 lifetime
  • similar to other medically ill populations
  • Substance induced mood disorder
  • Medical illness induced
  • must distinguish from dementia, hypoactive or
    hyperactive delirium

16
ANXIETY DISORDERS
  • 2 to 38 of patients depending on stage of
    illness
  • Panic disorder
  • Adjustment disorder
  • Substance induced due to intoxication or
    withdrawal
  • Medical illness induced, e.g. untreated pain

17
SUBSTANCE ABUSE AND DEPENDENCE
  • Abuse
  • recurrent use in setting of failure at work, home
    or school
  • use in physically hazardous settings
  • recurrent legal problems
  • recurrent social or interpersonal problems

18
SUBSTANCE ABUSE AND DEPENDENCE
  • Dependence
  • tolerance/withdrawal
  • larger amounts/longer period of time
  • unable to cut down or control use
  • time spent obtaining drug or recovering from it
  • love, work or play compromised
  • use in setting of physical/psychological problems

19
SUICIDE ASSESSMENT
  • Gender M gt F
  • Age 15-25 years and gt 45 years men gt 55
    years women
  • Ethnicity Caucasian (Black, Hispanic, Native
    American)

20
SUICIDE ASSESSMENT
  • Family history
  • suicide, early parental loss, mood disorder,
    chaos
  • Psychiatric illness
  • auditory hallucinations, mood disorder, substance
    use, prior attempts
  • Medical illness
  • acute v chronic, terminal, pain, medications

21
SUICIDE ASSESSMENT
  • Behavioral factors
  • Changes in behavior
  • Messages saying goodbye
  • Social isolation
  • Lethality
  • Access to means -Thorough plan
  • Method of attempt -Prior attempts
  • Possibility of rescue

22
SUICIDE ASSESSMENT
  • HIV/AIDS Risk Factors
  • Stage of disease
  • Number of AIDS related losses
  • Social isolation
  • Disease progression/fear of progression
  • Uncontrolled pain
  • Experience with HIV-related suicide

23
SUICIDE INTERVENTIONS
  • Medication/hospitalization
  • Address contributing factors
  • Encourage expression of feelings/thoughts
  • Promote sense of self control
  • Build alternative coping strategies
  • Educate patient and family
  • Develop a crisis plan

24
TREATMENT
  • Psychotherapy
  • supportive, interpersonal, cognitive-behavioral,
    group, psychoeducational
  • ongoing risk of crises
  • countertransference issues
  • homophobia, sex, substance use, existential
    beliefs, rescue fantasies, identification,
    therapeutic nihilism, guilt, fear of contagion

25
TREATMENT
  • Pharmacotherapy
  • Antidepressants
  • SSRIs Paroxetine, Sertraline, Fluoxetine
  • TCAs Nortriptyline, Desipramine
  • Other Nefazodone, Venlafaxine, Mirtazapine
  • Stimulants
  • Methylphenidate
  • Dextroamphetamine
  • Testosterone

26
TREATMENT
  • Pharmacotherapy
  • Antipsychotics
  • typical haloperidol
  • atypical risperidone, olanzapine
  • Antianxiety agents
  • benzodiazepines
  • Mood stabilizers
  • lithium, valproic acid, carbamazepine

27
MEDICATION INTERACTIONS
  • Multiple medications
  • Multiple medical illnesses
  • Renal or hepatic disease
  • Elderly
  • Individual differences in liver metabolism
  • Specific liver metabolism inhibitors

28
CHOOSING MEDICATIONS
  • Adverse effects
  • Interactions with other medications/drugs
  • Metabolism via liver
  • Elimination via liver or kidney or both
  • Time to expected onset of action
  • Expected duration of action
  • Less is better

29
SUMMARY
  • Document HIV status
  • Determine level of immunocompromise
  • Thorough history and physical exam
  • Diagnostic tests
  • CT/MR -Urine tox screen/BAL
  • LP
  • Neuropsychological testing

30
SUMMARY
  • HIV-related illness
  • Other physical disorder
  • Medication toxicity
  • Substance use
  • Primary psychiatric illness
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