April 2003 April 2003 HIV AND PSYCHIATRIC ILLNESS HIV AND PSYCHIATRIC ILLNESS • Karina K. Uldall, MD, MPH • Department of Psychiatry • HIV/AIDS Research Program • University of Washington
Dec 26, 2015
April 2003April 2003
HIV AND PSYCHIATRIC ILLNESSHIV AND PSYCHIATRIC ILLNESS
• Karina K. Uldall, MD, MPH
• Department of Psychiatry
• HIV/AIDS Research Program
• University of Washington
April 2003April 2003
OVERVIEWOVERVIEW
• AIDS Defining Neurological Illnesses
• Other CNS Disorders
• Psychiatric Illness in HIV/AIDS
• Diagnosis and Treatment
April 2003April 2003
AIDS DEFINING NEUROLOGICAL AIDS DEFINING NEUROLOGICAL ILLNESSILLNESS
• CMV Encephalitis
• Progressive Multifocal Leukoencephalopathy (PML)
• Toxoplasma Encephalitis
• Primary CNS Lymphoma
• Cryptococcal Meningitis
• Rarely TB Meningitis and Kaposi’s Sarcoma
April 2003April 2003
CMV ENCEPHALITISCMV ENCEPHALITIS
• Disorientation, confusion, apathy
• Psychomotor retardation, lethargy, cranial nerve abnormalities
• Abrupt onset, short course
• CD4 count < 50/uL
• Diagnosed via CSF PCR
• Treated with foscarnet, ganciclovir, both
• Survival less than 2 months
April 2003April 2003
PROGRESSIVE MULTIFOCAL PROGRESSIVE MULTIFOCAL LEUKOENCEPHALOPATHYLEUKOENCEPHALOPATHY
• Occurs in approximately 4% of patients
• Focal weakness, visual loss
• 10% spontaneously improve
• CD4 count < 100/uL
• Diagnosed via CSF JC virus PCR
• No clear treatment
• Survival 1 to 4 months
April 2003April 2003
TOXOPLASMA TOXOPLASMA ENCEPHALITISENCEPHALITIS
• 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 < 200/uL• Contrast scan - multiple enhancing lesions,
basal ganglia, gray-white junction• Treated with pyrimethamine/sulfadiazine
April 2003April 2003
PRIMARY CNS LYMPHOMAPRIMARY CNS LYMPHOMA
• Approximately 3-5% of HIV patients
• Second most common CNS mass in AIDS
• Presentation depends on location of tumor
• CD4 count < 100/uL
• Contrast scan - usually single lesion noted
• Treated with radiation
• Survival 2 to 6 months
April 2003April 2003
CRYPTOCOCCAL MENINGITISCRYPTOCOCCAL MENINGITIS
• Occurs in approximately 7% of HIV patients
• Fever, headache, cognitive changes
• Insidious onset spanning 2 to 4 weeks
• CD4 count < 100/uL
• Diagnosed via CSF culture, India ink stain
• Treated with amphotericin B and fluconazole
April 2003April 2003
OTHER CNS DISORDERSOTHER CNS DISORDERS
• Bacterial/Viral Meningitis
• Neurosyphilis
• Herpes Simplex Encephalitis
• Varicella-Zoster Encephalitis
• Rarely Histoplasmosis and Coccidiodomycosis
April 2003April 2003
PSYCHIATRIC ILLNESS IN HIV/AIDSPSYCHIATRIC ILLNESS IN HIV/AIDS
• HIV Associated Dementia (HAD)
• Delirium
• Psychotic Disorders
• Mood Disorders
• Anxiety Disorders
• Substance Abuse and Dependence
April 2003April 2003
HIV ASSOCIATED DEMENTIAHIV ASSOCIATED DEMENTIA
• 15-20% of AIDS patients
• Combination of motor, cognitive and mood/personality changes
• Insidious onset, CD4 count < 200/ul
• CSF Beta-2-microglobulin > 3.8 mg/dL, HIV-1 RNA >10,000/ml
• AZT, AZT+3TC, d4T+3TC, Indinavir
April 2003April 2003
DELIRIUMDELIRIUM
• 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)
April 2003April 2003
DELIRIUMDELIRIUM
• 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
April 2003April 2003
PSYCHOTIC DISORDERSPSYCHOTIC DISORDERS
• Substance induced during intoxication or withdrawal
• Medical illness induced – must be distinguished from delirium– late stage HIV associated dementia
April 2003April 2003
MOOD DISORDERSMOOD 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
April 2003April 2003
ANXIETY DISORDERSANXIETY 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
April 2003April 2003
SUBSTANCE ABUSE AND SUBSTANCE ABUSE AND DEPENDENCEDEPENDENCE
• 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
April 2003April 2003
SUBSTANCE ABUSE AND SUBSTANCE ABUSE AND DEPENDENCEDEPENDENCE
• 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
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SUICIDE ASSESSMENTSUICIDE ASSESSMENT
• Gender M > F
• Age 15-25 years and > 45 years men; > 55 years
women
• Ethnicity Caucasian (Black, Hispanic, Native American)
April 2003April 2003
SUICIDE ASSESSMENTSUICIDE 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
April 2003April 2003
SUICIDE ASSESSMENTSUICIDE 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
April 2003April 2003
SUICIDE ASSESSMENTSUICIDE 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
April 2003April 2003
SUICIDE INTERVENTIONSSUICIDE 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
April 2003April 2003
TREATMENTTREATMENT
• 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
April 2003April 2003
TREATMENTTREATMENT
• Pharmacotherapy– Antidepressants
• SSRIs Paroxetine, Sertraline, Fluoxetine• TCAs Nortriptyline, Desipramine• Other Nefazodone, Venlafaxine, Mirtazapine
– Stimulants• Methylphenidate• Dextroamphetamine
– Testosterone
April 2003April 2003
TREATMENTTREATMENT
• Pharmacotherapy– Antipsychotics
• typical haloperidol• atypical risperidone, olanzapine
– Antianxiety agents• benzodiazepines
– Mood stabilizers• lithium, valproic acid, carbamazepine
April 2003April 2003
MEDICATION INTERACTIONSMEDICATION INTERACTIONS
• Multiple medications
• Multiple medical illnesses
• Renal or hepatic disease
• Elderly
• Individual differences in liver metabolism
• Specific liver metabolism inhibitors
April 2003April 2003
CHOOSING MEDICATIONSCHOOSING 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”
April 2003April 2003
SUMMARYSUMMARY
• Document HIV status
• Determine level of immunocompromise
• Thorough history and physical exam
• Diagnostic tests– CT/MR -Urine tox screen/BAL– LP– Neuropsychological testing
April 2003April 2003
SUMMARYSUMMARY
• HIV-related illness
• Other “physical” disorder
• Medication toxicity
• Substance use
• Primary psychiatric illness