- as manifestations of pathophysiologic processes - delerium, dementia.
Indirect Impact
- as a significant psychological stressor.
Psychosocial Responses
While psychiatric complications obviously occur during the clinical course of AIDS itself, psychological distress and psychiatric morbidity related to the disease are common in other populations as well. These subgroups include:
General population - fear of AIDS
Psychologically vulnerable - worried well - Hypochondriacs who keep thinking they have AIDS
High risk groups
HIV positive patient - time of greatest suicide risk
Patient with AIDS
Family of AIDS patients
Care providers working with AIDS patients
Modifiers of Stress Response
As with other threats to psychological well-being, there are marked variations in individual responses to disease. Variables that modify stress response include:
The disease progression and physical manifestations.
Life cycle phase.
Premorbid personality - defensive patterns and coping skills.
Other ongoing sources of distress.
Quality and quantity of social support including the medical care system.
Responses to AIDS Diagnosis or Other Catastrophic Information
Four Stages:
(1) Shock
- patients are numb, stop hearing/feeling things, become forgetful
(2) Denial
- used as a defense mechanism. 3 types of denial:
denial of fact
("he told me I’m HIV positive but I don’t believe it") - rare
denial of affect
("I’m enjoying everything in life") - can be a useful tool, but very brittle leading to depression
denial of implication
(I understand I have aids, but I feel fine and don’t have to change anything) - physicians don’t like this kind of patient: they don’t show up for appointments, don’t take meds, etc.; can be danger to public having unsafe sex.
(3) Active Accomodation
- can no longer deny illness and attempt to master it. Seen in majority of patients. Try to do everything they can to stay healthy. Search internet for facts. Worried about every little thing they feel thinking it has to do with AIDS.
(4) Acceptance
- significant progression of disease. Patient is disabled. Patient has accepted what’s going on. A sad time. Doctor has to help patient die with dignity. Support family members.
Psychological Reactions and Psychiatric Morbidity
Intensification
of premorbid defenses - compulsive patient becomes more compulsive, dependent patient becomes more dependent, etc.
Somatization
- increased preoccupation with body symptoms
Variations in the anxiety depression spectrum which may reach criteria for either adjustment disorder (emotional or behavioral symptoms that occur in response to some recognized stress) or major mood disorder.
Psychoses
- patient’s ego overwhelmed with what’s going on and lapse into delusional state.
Psychophysiologic relationships
(psychological factors affecting medical condition) - notion that psychological and social variables may impact on the immune system itself and influence disease outcome.
CNS complications
- delirium, dementia
Problems in diagnosis:
Signs and Symptoms common to depression and early dementia
: Decreased concentration, Forgetfulness, decreased interest, decreased sexual drive, apathy, blunted affect, psychomotor retardation or agitation, social withdrawal
More specific to depression
: sadness, helplessness, hopelessness, decreased self-esteem, worthlessness, unrealistic guilt, suicidal thoughts. It’s important to differentiate between dementia and depression!!!
Difference between grief and depression
: Grieving person thinks the world is wronging him, not his fault. Depressed person thinks it’s their fault, feel worthless.
Treatment of HIV
Start low, go slow. can use stimulants (Ritalin).
Care Providers
- Distress is often apparent in care providers who work with risk groups and people with AIDS. The phenomena of "burnout" includes psychological distress progressing to psychiatric symptoms, reduced work effectiveness, withdrawal and resignation. Burnout in AIDS workers is a significant problem for the medical care system