april 2003 hiv and psychiatric illness karina k. uldall, md, mph department of psychiatry hiv/aids...
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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
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April 2003April 2003
OVERVIEWOVERVIEW
• AIDS Defining Neurological Illnesses
• Other CNS Disorders
• Psychiatric Illness in HIV/AIDS
• Diagnosis and Treatment
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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
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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
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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
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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
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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
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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
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April 2003April 2003
OTHER CNS DISORDERSOTHER CNS DISORDERS
• Bacterial/Viral Meningitis
• Neurosyphilis
• Herpes Simplex Encephalitis
• Varicella-Zoster Encephalitis
• Rarely Histoplasmosis and Coccidiodomycosis
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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
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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
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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)
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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
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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
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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
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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
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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
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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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April 2003April 2003
SUICIDE ASSESSMENTSUICIDE ASSESSMENT
• Gender M > F
• Age 15-25 years and > 45 years men; > 55 years
women
• Ethnicity Caucasian (Black, Hispanic, Native American)
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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
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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
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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
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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
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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
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April 2003April 2003
TREATMENTTREATMENT
• Pharmacotherapy– Antidepressants
• SSRIs Paroxetine, Sertraline, Fluoxetine• TCAs Nortriptyline, Desipramine• Other Nefazodone, Venlafaxine, Mirtazapine
– Stimulants• Methylphenidate• Dextroamphetamine
– Testosterone
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April 2003April 2003
TREATMENTTREATMENT
• Pharmacotherapy– Antipsychotics
• typical haloperidol• atypical risperidone, olanzapine
– Antianxiety agents• benzodiazepines
– Mood stabilizers• lithium, valproic acid, carbamazepine
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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
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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”
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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
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April 2003April 2003
SUMMARYSUMMARY
• HIV-related illness
• Other “physical” disorder
• Medication toxicity
• Substance use
• Primary psychiatric illness