Saturday, November 27, 2010

Psychiatric Problems of AIDS Inpatients at the New YorkHospital:


GENERAL Psychiatric Problems of AIDS Inpatients at the New YorkHospital: Preliminary Report
SAMUEL W. PERRY, MD
SUSAN TROSS, PhD

Dr. Perry is associate of professor of psychiatry at Cornell University Medical College and associate director of consultationliaison  psychiatry at the New York Hospital, New York City. Dr. Tross is a psychology fellow at the Memorial Sloan-Kettering Cancer Center and instructor of psychology in psychiatry at Cornell
University Medical College. John Falkenberg, R.N., helped record the data. 

This work was supported by the National Institute of General  Medical Science's grant No. GM 26145 to the New York Hospital  Burn Center. Tearsheet requests to Samuel W. Perry, MD, 525 East 68th St.,
New York, N.Y. 10021.
Synopsis ....................................

A retrospective review of the charts of52 patients with  acquired immune deficiency syndrome (AIDS) in the New York Hospital was conducted to determine  the prevalence of recorded psychiatric complications and the use of
psychiatric consultation. Neuropsychiatric complications were found to be pervasive clinical features in AIDS patients hospitalized during acute illness. Mood disturbance was identified in an overwhelming majority of the patients (82.7 percent), and signs of organic mental syndrome (DSM III) were
noted in 65.4 percent; references to neuropsychiatric complications appeared in every patient's chart.


Neurological complications were seldom explicitly diagnosed or treated. Psychiatric consultation was requested for 10 patients (19.2 percent) because of management problems, for diagnostic assessment, or by selfreferral.
Only one patient was given a psychiatric diagnosis at discharge. The results suggest that the neuropsychiatric complications of AIDS are underdiagnosed
during acute medical illness and that psychiatric consultation is underutilized.
AIDS patients have a heightened risk of psychological problems. Contributing factors may include the threat to life, severe physical debilitation, central nervous system involvement, fear of contagion, disclosure of homosexuality
or drug abuse, and guilt associated with sexual transmission. SINCE THE FIRST REPORrED CASES IN 1981 (1), acquired immune deficiency syndrome (AIDS) has been identified as a public health emergency. As ofDecember 12, 1983,
a total of 2,952 cases had been reported to the Centers for Disease Control (CDC), and 1,225 of these patients (42 percent) had died (2). Among high-risk groups, the mean number of cases was doubling every 6 months, but
may now be increasing at a lower rate. These groups are homosexual or bisexual men, especially those with multiple sexual partners-71 percent of the cases (1,3-5);  intravenous drug users-17 percent (6); and hemophilia
A patients treated with Factor VIII-1 percent (7). The  Public Health Service regards recent Haitian immigrants  (less than 7 percent) as a high-risk group. However, there has been controversy about this categorization (8,9).
The current definition of AIDS used in CDC's surveillance  activities requires the presence of a disease at  least moderately indicative of defective cell-mediated immunity in a person who has no known underlying cause for such a defect or any other reason for diminished resistance to disease (10). Diseases that are indicative of AIDS include Pneumocystis carinii pneumonia
(PCP) with or without other opportunistic infections, 51 percent of the cases; Kaposi's sarcoma (KS) with or without opportunistic infection, 26 percent; other opportunistic infections alone, 15 percent; or KS and PCP with or without other opportunistic infection, 8 percent (2). Although the cause of AIDS is not known, a major current theory favors exposure to an unidentified viral agent to which the immunosuppressed individual is more vulnerable (11-15). The treatment of opportunistic infections has included trimethoprim-sulfamethoxazole,
ketoconazole, acyclovir, and pentamidine. Treatment for KS has included recombinant leukocyte A interferon, radiotherapy to the skin, and systemic chemotherapy (doxorubicin, vinblastine, bleomycin). These treatments
for opportunistic infections or KS may provide transient relief of symptoms, but there is no evidence that they improve the overall survival rate (16).
The psychiatric aspects of AIDS await systematic documentation. Although writers in the media (17,18), psychotherapists (19,20), and authors in medical journals  200 Public Health Reports (21-23) have suggested that emotional reactions to the illness can be quite pronounced, these observations have
often been based on impressions and not on scientific data. This problem has been compounded by a lack of specificity in published reports and a failure to distinguish different kinds of psychiatric complications during different phases of the illness.
These psychiatric complications may include (a) adjustment
reactions at time of confirmed diagnosis (for
example, numbness, shock, and denial); (b) adjustment
reactions during progression of the illness (for example,
depression, self-imposed or peer-inflicted isolation, and
guilt about sexual or drug-related behavior; (c) intense
emotional reactions in members of high-risk groups with
no evidence of the disease (for example, anxiety about
contracting AIDS, somatic preoccupation, convictions of
discrimination, forced attempts to change sexual preference,
and anger at the perceived insensitivity and impotence
of the medical establishment); and (d) exaggerated
emotional reactions in individuals who are not members
of high-risk groups (for example, homophobia or unreasonable
fears of contagion).
In addition to these emotional reactions, organic
symptoms arising from AIDS itself or from its therapy
may present psychiatric complications. Fatigue and
weight loss may signal the prodromal phase of AIDS and
may mimic major depression. A "flu-like" complex of
lethargy, fever, and depressed mood has been associated
with recombinant leukocyte A interferon (24). Central
nervous system diseases, especially encephalitis (25) and
primary lymphoma (26), frequently produce cognitive
deficits, mood disturbance, vegetative signs, personality
change, and impulsive behavior that mimic psychogenic
disorders.
Methods
To provide effective care, physicians must be able to
anticipate the frequency, nature, and severity of neuropsychiatric
problems in the AIDS population and recommend
useful psychological interventions. We reviewed
the medical charts of all adults meeting CDC criteria for
AIDS (10) who were admitted to the New York Hospital,
New York City, between September 1, 1981, and September
1, 1983.
We reviewed the notes of physicians, nurses, social
workers, and medical students, and we recorded neuropsychiatric
symptoms and adjustment problems on the
basis of face validity. When a psychiatric consultation
had been requested, the reasons for consultation, diagnostic
impression and recommendations for treatment
were noted. The senior author (S.W.P.) interviewed the
psychiatrists, physicians, and other personnel familiar
with the patients to obtain more detailed information
about the nature and resolution of the presenting problem.
All references to adjustment problems and psychiatric
symptoms were noted. In addition to this review, we
explored the implications of the detection and management
of psychological problems of AIDS patients.
Results
During the 2-year period, 83 adult patients with AIDS
were admitted to the New York Hospital. Complete medical
records were available for 52 of these patients (62.6
percent).
Table 1 lists relevant. sociodemographic and medical
characteristics of the population studied. The majority of
patients were middle-class homosexual men in their 30s,
a small portion of whom also infrequently used intravenous
drugs. Only two patients (including the woman)
denied belonging to any high-risk group. Opportunistic
infection (primarily PCP, mucosal candidiasis, and disseminated
cytomegalovirus) occurred in 43 patients
(82.7 percent) and was regarded as the most critical
medical problem. A large portion of the study population
was terminally ill: at least 19 patients (36.5 percent) died
during hospitalization or within 6 weeks after discharge.
Psychiatric diagnosis detected by chart review are
summarized in table 2. Thirty-one patients (59.6 percent)
met criteria in the Diagnostic and Statistical Manual
of Mental Disorders, third edition (DSM IIl) for one
or more psychiatric diagnoses (27). The most common
DSM III diagnosis was organic mental syndrome (OMS)
with or without a major depression, which was present in
21 patients (40.4 percent). Major depression was present
in nine patients (17.3 percent). However, only the patient
Table 1. Sociodemographic and medical characteristics of 52
hospitalized AIDS patients'
Charactenstic Number Percent
Sex:
Male ............... .............. 51 98.1
Female ............. ............. 1 1.9
Risk group:
Homosexual-bisexual .............. 41 78.8
Homosexual-intravenous drug user .. 5 9.6
Haitian immigrant .......... ....... 3 5.8
Intravenous drug user ........ ..... 1 1.9
Undetermined .................... 2 3.8
Primary medical illness:
Opportunistic infection ........ ..... 3771.2
Kaposi's sarcoma .......... ....... 9 17.3
Both opportunistic infection and
Kaposi's sarcoma ......... ...... 6 11.5
Mortality:
Dunng hospitalization ........ ...... 11 21.2
Known following discharge ......... 8 15.4
1 Mean age: 36 ± 2.1 years (range: 20-69).
March-April 1984, Vol. 99, No. 2 201
Table 2. DSM III and presumptive diagnoses of 52 hospitalized
AIDS patients
Diagnoses Number Percent
Mood disturbance:
DSM IlIl major depression .......... 9 17.3
Presumptive depression ...... ...... 34 65.4
Total ......................... 43 82.7
Organic mental syndrome:
DSM III delirium .......... ........ 15 28.8
DSM IlIl dementia ......... ........ 6 11.5
Presumptive organic mental
syndrome ...................... 13 25.0
Total ......................... 34 65.4
Other diagnoses:
Substance abuse disorder ......... 6 11.5
Schizophrenia .................... 1 1.9
with chronic undifferentiated schizophrenia actually received
a psychiatric diagnosis at discharge.
References to neuropsychiatric complications-such
as being depressed, anxious, lethargic, or withdrawnappeared
in the charts of all 52 patients. These references
indicated neuropsychiatric problems in some patients
whose medical records did not supply sufficient information
to make a DSM III diagnosis. In addition to 21
diagnoses of DSM III delirium or dementia, a presumptive
diagnosis of OMS was strongly suggested for
13 patients (for example, repeated nurses' notes stating
that the patient was "confused" or "disoriented"). Nine
patients met DSM III criteria for major depression; mood
disturbance was strongly suggested in 34 other patients
but the recorded information was not sufficient to distinguish
a primary affective disorder from a normal grief
response or a mood impairment secondary to neurological
or systemic disease. Five patients had suicidal
ideation (9.6 percent), but only one patient was considered
a suicidal risk (1.9 percent). Forty-three patients
(82.7 percent) were noted to have an aberrant lifestyle
(for example, antisocial behavior or chaotic interpersonal
relationships), but no record provided sufficient detail to
meet DSM III criteria for a personality disorder.
Management problems were encountered in seven patients
(13.5 percent). Three of these patients left the
hospital against medical advice; one was subsequently
readmitted and another was followed as an outpatient.
Two patients refused to comply with medication or a
diagnostic procedure; a few days later, both of these
developed a delirium and died. Two patients were considered
belligerent or abusive to staff when their demands
for more narcotic analgesics were not met.
Psychiatric consultation was requested for 10 patients
(19.2 percent) because of the management problems described
previously, for diagnostic assessment, or by selfreferral.
The six management problems occurred when
patients refused procedures, had explosive episodes on
the ward, or signed out against medical advice; two
patients in this group left abruptly before consultation.
(The number of patients actually seen by a psychiatrist
therefore differs from the number of requests for consultation.)
In the two patients seen for diagnostic assessment,
the psychiatrist was asked to help distinguish
organic from psychogenic pathology. Two consultations
were performed at the patients' initiative because of "depression."
Case vignettes. The following case vignettes illustrate
the three major reasons for psychiatric consultation:
1. Management problems. Mr. A., a 30-year-old
homosexual musician, had been hospitalized for several
weeks because of gastrointestinal infections and renal
failure. Psychiatric consultation was sought after a nurse
observed that he was not taking his prescribed medicine.
During the first two interviews, the psychiatrist was not
certain whether noncompliance stemmed from hopelessness
or from a chronic tendency to be manipulative
and passive-aggressive. During the third interview, the
consultant observed how the patient fluctuated between
hypervigilance and indifference and how he avoided formal
testing of cognitive functions. The psychiatrist suspected
that a mild OMS was exaggerating personality
problems; she therefore recommended that the staff appreciate
the patient's confusion and that a neurological
evaluation be made. The patient immediately responded
to less complicated explanations and began taking his
medications; he had a grand mal seizure 4 days later and
soon died from encephalitis.
2. Diagnostic assessment. Mr. B., a 49-year-old married
bisexual executive, was referred for psychiatric consultation
18 months after AIDS was first diagnosed
(PCP). During the early stages of his illness-both because
of an unrecognized mild OMS and because of
depression causing him to drink alcohol-he had driven
his successful business to financial collapse and destroyed
his family life. By the time of his second hospitalization
for disseminated cytomegalovirus, he had lost
70 pounds, was going blind, and was living a marginal
existence in his elderly mother's apartment.
The manifest reason for psychiatric referral was to
determine the role depression was playing in a man with
a now well-documented case of dementing encephalitis.
After the first interview, the consultant suspected a latent
reason for the referral because at that point the diagnostic
distinctions between psychogenic and organic causes appeared
academic: Mr. B. was so cachectic and debilitated
202 Public Health Reports
he could not lift his head from the pillow and could not
maintain the most superficial conversation before drifting
back to sleep. He was not oriented to time or place,
could not name any President, and had neither immediate
nor short-term recall.
Recognizing that the patient was terminally ill, the
psychiatrist directed his efforts toward the referring staff
members who were depressed themselves. A liaison staff
conference enabled them to work through the discouragement
and hopelessness they felt watching AIDS
patients die despite heroic efforts.
3. Self-referral. Mr. C., a 39-year-old homosexual
artist, requested a psychiatric consultation during his
second admission for PCP and KS. During the interview,
though weak and sickly, he was able to maintain his
flamboyant style and poignantly convey his fears of
"walking alone towards death." Geographically and
emotionally distant from his relatives, he had relied on
support from friends and a homosexual self-help group
since his first admission, but he now wanted an "insider"
who was "not political" or intimidated by "the
parade of doctors and the stench of specimens." In
response to the patient's request, the psychiatrist met
with Mr. C. frequently throughout his prolonged hospitalization
to facilitate his profound grief response and to
help explain the bewildering array of tests and procedures.
Mr. C. met "the approaching shadow" without
the panic and awesome loneliness he had feared.
Discussion
On the basis of a retrospective review of the charts of
52 hospitalized patients, mood disturbance and cognitive
dysfunction were found to be a pervasive clinical feature
of AIDS. Although neuropsychiatric symptoms could be
identified in every record, they were rarely diagnosed or
treated. Only one patient received a psychiatric discharge
diagnosis, and psychiatric consultation was requested for
fewer than one in five patients. Thus, AIDS patients are
at high risk for psychological problems, but these problems
tend to be underdiagnosed and undertreated. Five factors may help explain these observed tendencies: sample bias, rater bias, preoccupation with severe
medical complications, failure to appreciate the high incidence of OMS in AIDS patients and the benefits of palliative treatment, and avoidance of emotional issues in homosexual, "contagious," and fatally-ill patients. 

1. Sample bias. The population was mainly composed
of white middle-class homosexuals in their 30s.
Only one patient (1.9 percent) was a heterosexual intravenous
drug abuser,

Psychiatric complications may be more readily recognized
in drug abusers or indigent patients either because
their problems are more pronounced or because health
personnel are less inclined to overidentify with patients
who are more obviously different in their sociocultural
background and lifestyle.


2. Rater bias. Because the assessments were made on
the basis of face validity, the psychological orientation of
the raters may have prejudiced the findings, increased the
significance of references to neuropsychiatric problems,
and underestimated implicit therapeutic interventions.
3. Severe medical complications. By design, this review
included only those subjects requiring hospitalization.
All the patients were critically ill; at least 19 (36.5
percent) died during the 2-year study period. The need
for intensive medical care may have diverted attention
from neuropsychiatric problems that neither the staff nor
the patients considered life-threatening. Possibly more
attention would have been given to psychological issues
if acute medical problems were not an overwhelming
preoccupation.
4. Unrecognized organic mental syndrome (OMS).
Twenty-one patients (40.4 percent) met DSM III criteria
for an OMS; confusion, disorientation, loss of memory,
and other organic signs were described in 13 additional
patients (25 percent). The high incidence of cognitive
dysfunction in these patients is consistent with recent
studies that have described the frequent neurological
complications of AIDS (25,26), yet only those patients
seen in psychiatric consultation were explicitly given an
OMS diagnosis. More importantly, according to the
medical records, palliative treatment for dementia or
delirium was given to only those patients whose OMS
was identified.
The general failure to diagnose and treat OMS in
hospitalized medical patients has been documented
(28-31). The cases of Mr. A. and Mr. B. illustrate that
the staff may not realize that mild cognitive impairment
is a factor contributing to noncompliance, depression,
and altered behavior.
5. Avoidance of emotional issues. Although the subtle
attitude of caretakers cannot be adequately substantiated
by a chart review, the relatively low incidence of
recorded psychopathological reactions raises the possibility
that staff members consciously or unconsciously
avoided emotional issues with these patients. The rate of
requests for psychiatric consultation was one-third the
usual rate for ward medical services that have an active
consultation-liaison program. Furthermore, no consultation
was requested by the staff to help patients cope with
March-April 1984, Vol. 99, No. 2 203
the psychological stresses of the illness; the requests
were for management problems, for diagnostic assessment,
or at the patient's request.
There are a few explanations for this lapse in psychiatric
consultation. Staff members may have believed psychiatric
intervention would be futile for patients who
were critically ill, or they may have wished to remain
detached from the difficult emotional issues in dying
patients. These general tendencies have been described
with other kinds of patients (32-34), but may be compounded
with AIDS patients by fears of contagion (35),
homophobia (36), or, as illustrated by the case of Mr. B.,
the staff's own hopelessness in treating a large series of
enigmatic terminally ill patients. Additionally, patients
themselves may have wished to minimize their neuropsychological
problems or may have chosen to discuss
these problems with their own friends and counselors
because they considered the medical staff to be unsympathetic,
or at least unfamiliar, with homosexual issues.
Recommendations for Psychiatric Intervention
Based on the results of this study at the New York
Hospital, we recommend the following measures to deal
with the neuropsychiatric complications of AIDS during
medical hospitalization:
1. Document mental status. The high incidence of
OMS recently associated with this population (25,26)
provides a compelling argument for routine monitoring
of the mental status of every AIDS patient. The Mini-
Mental State examination (37,38) may help detect the
mild OMS that frequently occurs early in the course of
the disease. Disorders of mood, thinking, or behavior
should not presumptively be viewed as psychogenic until
a systematic mental status examination has ruled out
possible cognitive (organic) determinants. Depression,
lethargy, impulsivity, explosive episodes, and noncompliance
may be secondary to the nervous system
dysfunctions associated with subacute encephalitis, lymphomas
of the central nervous system, vascular complications,
and other neurological and systemic problems.
If the diagnosis of an OMS is recognized and
recorded, the staff will be alerted to provide specific
palliative treatment, including neuroleptics; correction of
misinterpretations; and simplified instructions and explanations
(39-41).
2. Identify and treat avoidance of psychological issues.
The limited requests for psychiatric consultation
and the paucity of recorded information regarding psychological
aspects suggest that the staff may be inclined
to avoid emotional issues with these AIDS patients,
thereby enhancing their sense of being different. Staff
education can be helpful in (a) explaining what is known
about the transmission of the disease, thus reducing unreasonable
precautions and fears of contagion (35); (b)
providing information about homosexual behavior to correct
distortions and decrease homophobia; and (c) indicating
(as with Mr. C.) that the psychiatric reactions of
patients hospitalized with AIDS are not dissimilar to
reactions of other kinds of patients who have a lifethreatening
illness (fears of pain, abandonment, debility,
dependency, and separation). These familiar reactions
can potentially respond to the same psychotherapeutic
and psychopharmacological interventions proven to be
effective for other medically ill patients.
3. Arrange for aftercare. Hospitalization provides an
opportunity to marshal family, peer, legal, and social
support. Psychological problems may surface or at least
become more apparent after the acute medical crises
pass. In communities where AIDS is most prevalent,
homosexual organizations provide support groups,
trained counselors, supervised social activities, homemakers,
and a buddy system to accompany AIDS victims
to outpatient appointments.
Conclusion
Neuropsychiatric complications, especially cognitive
dysfunction and mood impairment, were pervasive
clinical features in AIDS patients hospitalized during
acute illness, but those complications were seldom explicitly
diagnosed or treated. The results of any retrospective
chart review must be interpreted cautiously, but
there is a strong suggestion that a thorough mental status
examination will detect neuropsychiatric complications
in an overwhelming majority of hospitalized AIDS patients.
When these complications are detected and diagnosed
and when the sources of distress are appreciated,
effective supportive and palliative interventions can be
prescribed.


Our findings are a preliminary step in alerting clinicians
to the neuropsychiatric problems of AIDS patients.
To document the prevalence and severity of these problems
more systematically, we are conducting a controlled
prospective study of newly diagnosed AIDS patients.

2 comments:

  1. My life is beautiful thanks to you, Mein Helfer. Lord Jesus in my life as a candle light in the darkness. You showed me the meaning of faith with your words. I know that even when I cried all day thinking about how to recover, you were not sleeping, you were dear to me. I contacted the herbal center Dr Itua, who lived in West Africa. A friend of mine here in Hamburg is also from Africa. She told me about African herbs but I was nervous. I am very afraid when it comes to Africa because I heard many terrible things about them because of my Christianity. god for direction, take a bold step and get in touch with him in the email and then move to WhatsApp, he asked me if I can come for treatment or I want a delivery, I told him I wanted to know him I buy ticket in 2 ways to Africa To meet Dr. Itua, I went there and I was speechless from the people I saw there. Patent, sick people. Itua is a god sent to the world, I told my pastor about what I am doing, Pastor Bill Scheer. We have a real battle beautifully with Spirit and Flesh. Adoration that same night. He prayed for me and asked me to lead. I spent 2 weeks and 2 days in Africa at Dr Itua Herbal Home. After the treatment, he asked me to meet his nurse for the HIV test when I did it. It was negative, I asked my friend to take me to another nearby hospital when I arrived, it was negative. I was overwhite with the result, but happy inside of me. We went with Dr. Itua, I thank him but I explain that I do not have enough to show him my appreciation, that he understands my situation, but I promise that he will testify about his good work. Thank God for my dear friend, Emma, I know I could be reading this now, I want to thank you. And many thanks to Dr. Itua Herbal Center. He gave me his calendar that I put on my wall in my house. Dr. Itua can also cure the following diseases ... Cancer, HIV, Herpes, Hepatitis B, Inflammatory Liver, Diabetis, Bladder Cancer,Colorectal Cancer,HPV,Breast Cancer,Kidney Cancer,Leukemia,Lun,Fribroid,Infertility,Parkinson's disease,Inflammatory bowel disease ,Fibromyalgia, recover your ex. You can contact him by email or whatsapp, @ .. drituaherbalcenter@gmail.com, phone number .. + 2348149277967 .. He is a good doctor, talk to him kindly. I'm sure he will also listen to you.

    ReplyDelete
  2. I have long felt a special connection with herbal medicine. First, it's natural, Charlie attended the same small college in Southern California - Claremont Men's College - although he dropped out of school to enroll in the Julliard School of Performing Arts in New York. York. Had he been to Claremont, he would have been senior the year I started there; I often thought that was the reason he was gone when he discovered that I had herpes. So, my life was lonely, all day, I could not stand the pain of the outbreak, and then Tasha introduced me to Dr. Itua who uses her herbal medicines to cure her two weeks of consumption. I place an order for him and he hands it to my post office, then I pick it up and use it for two weeks. All my wound is completely healed no more epidemic. I tell you honestly that this man is a great man, I trust him Herbal medicine so much that I share this to show my gratitude and also to let sick people know that there is hope with Dr. Itua. Herbal Center.Dr Itua Contact Email.drituaherbalcenter@gmail.com/Whatsapp ... 2348149277967
    He cures.
    Herpes,
    Prostate
    Breast Cancer
    Brain Cancer
    CEREBRAL VASCULAR ACCIDENT.
    ,Endomertil Cancer, cerebrovascular diseases
    Hepatitis,Glaucoma., Cataracts,Macular degeneration,Cardiovascular disease,Lung disease.Enlarged prostate,Osteoporosis.Alzheimer's disease,
    Dementia.Tach Disease,Shingles,
    Lung Cancer, Leukemia Lymphoma Cancer,
    Lung Mesothelioma Asbestos,
    Ovarian Cervical Uterine Cancer,
    Skin Cancer, Brain Tumor,
    H.P.V TYPE 1 TYPE 2 TYPE 3 AND TYPE 4. TYPE 5.
    HIV,Arthritis,Amyotrophic Lateral Scoliosis,Fibromyalgia,Fluoroquinolone Toxicity
    Cervical Cancer
    Colo-rectal Cancer
    Blood Cancer
    SYPHILIS.
    Diabetes
    Liver / Inflammatory kidney
    Epilepsy

    ReplyDelete