Mary Alice O'Dowd

A prospective longitudinal study of neuropsychological and psychosocial factors in asymptomatic individuals at risk for HTLV-III/LAV infection in a methadone program: preliminary findings.

To test the hypothesis that cognitive impairment may be present early in the course of HTLV-III/LAV infection, intravenous drug abusers (IDVAs) without overt symptoms of AIDS related illness were tested with standard neuropsychological and psychosocial measures. This study is the baseline for a prospective longitudinal study of the natural history of HTLV-III/LAV infection in this high risk population. Of 211 subjects initially evaluated, 70 (33%) were HTLV-III/LAV seropositive and 141 (67%) were seronegative. At the baseline, by univariate analysis, the seropositive IVDAs were significantly (p less than .05) more impaired than seronegatives on 4 of 8 measures: Finger Tapping--dominant, hand, Digit Span Forward, Trail making A and WAIS-Similarities. However, by multivariate analysis the seropositives were significantly more impaired only on the WAIS-Similarities and Wechsler--Associative Learning tests. Multiple factors such as drug use and psychological stress may have influenced test performance. These preliminary results, however, suggest that seropositive IVDAs may show evidence of impaired neuropsychological function even in the absence of AIDS related symptoms and are consistent with the hypothesis of the early neurotropism of HTLV-III/LAV.

Coping and psychological distress in women with HIV/AIDS

The relationship between coping strategies and anxiety and depression was investigated in 29 women patients with acquired immune deficiency syndrome (AIDS) or human immunodeficiency virus (HIV) infection, at a psychiatric AIDS clinic. The women were divided on the basis of risk factor, intravenous drug use (IVDU), and nonintravenous drug use (non-IVDU), and coping strategies were compared. Based on a battery of psychological tests, the coping strategies of self-blaming denial, wish-fulfilling fantasy, emotional expression, and threat minimization were significantly related to greater anxiety and depression. There was no difference in coping strategies between the IVDUs and non-IVDUs, and none of the coping strategies employed appeared to be associated with less anxiety or depression. This may have been due to the psychiatric AIDS clinic sample, possibly representing the more distressed group of HIV/AIDS patients, for whom coping strategies were overwhelmed.

AIDS patients compared with others seen in psychiatric consultation

To identify similarities and differences between AIDS patients and non-AIDS patients, all psychiatric consultations done in one year in a large voluntary general hospital were reviewed. A total of 93 consultations were done on 67 AIDS patients and 138 consultations were done on 121 comparably aged patients without AIDS. The most common AIDS risk factor was intravenous drug use. The AIDS patients were more likely to be Hispanic and male than were the non-AIDS patients. The AIDS group was also more likely to have a diagnosis of organic mental disorder, particularly dementia. There were no other differences in Axis I diagnoses, including depression, substance abuse, and adjustment disorder. Suicidal risk was no greater in the AIDS patients than in the non-AIDS patients. Axis II diagnoses were made more often in the non-AIDS patients, who also required more one-to-one nursing supervision. Consultation in AIDS patients took more staff time, and AIDS patients were more likely to have required one or more repeat consultations within the period of the study, thus creating a heavier burden on consultation staff. Although these predominantly heterosexual, Hispanic, and drug-using hospitalized AIDS patients do not show significantly higher rates of psychiatric morbidity than other, non-AIDS patients, except for more organic mental disorders, AIDS seems to create a much higher demand for psychiatric consultation services.

A prospective four-year follow-up of neuropsychological function in HIV seropositive and seronegative methadone-maintained patients

The evolution of central nervous system (CNS) impairments associated with human immunodeficiency virus (HIV) infection was assessed by a prospective, longitudinal study of patients in a methadone maintenance clinic. At a mean of 47 months after baseline testing, which included physical exams, HIV antibody testing and a neuropsychological (NP) screening battery, 121 subjects received a second NP assessment. Forty subjects (33%) who were seropositive at baseline showed statistically significant declines in NP function over the 4 years compared with 81 seronegatives, on the Finger Tapping and Trail Making B tests. This relatively long-term follow-up suggests that subtle cognitive deficits develop over time and can be identified early, but their course is slow and appears generally to parallel that of non-CNS symptoms/signs of HIV infection.

Development of an optically scanned Consultation-Liaison data base

Every clinical service must record certain data about its patient care activities. In low-volume services, such as Psychiatric Inpatient Services, with perhaps 20-30 admissions per month, and an average patient stay of 2-4 weeks, a large amount of data on each patient can be obtained during the contact time with the patient. On the other hand, very large-volume psychiatric services, such as Emergency and Consultation-Liaison (C-L) Services, may not need or be able to gather such a large amount of data on every patient seen. This article describes the development of a brief, optically scannable, and computerized minimal data base form for patients seen by a very large division of C-L Psychiatry. The system is feasible and easily auditable for completeness and reliability. This data base has already served many important functions beyond providing an administrative statistical summary of services rendered. It is presented as a model for the development of similarly efficient data collection methods for other high-volume psychiatric services.

Depression, HIV dementia, delirium, posttraumatic stress disorder (or all of the above)

A 29-year-old single Puerto Rican woman with AIDS was admitted to the Medical Service for pneumonia, seen by the Psychiatric Consultation Service, an eventually transferred to the Inpatient Psychiatric Unit with several possible psychiatric diagnoses including major depression, HIV dementia, delirium, and posttraumatic stress disorder. These possibly coexisting and interacting syndromes are discussed by three psychiatrists, one of whom is also a board-certified neurologist. This case illustrates the combined contribution of organic and psychological factor to complex behavioral disorders, which are increasingly common in HIV infection.

Delayed Diagnosis of Sporadic Creutzfeldt-Jakob Disease in a Patient with Schizophrenia

Human transmissible spongiform encephalopathies, also known as prion diseases, are caused by abnormal folding of normal prion proteins in the brain. Sporadic Creutzfeldt-Jakob Disease (sCJD), the most common prion disease, occurs at an annual rate of one in 1 million and often leads to a fatal outcome within a year. The mean age of onset is 55 to 75 years old. sCJD is a cause of rapidly progressive dementia but because of its rarity, may not be on the differential diagnosis in its earlier stages of manifestation, particularly if a patient lacks other neurological symptoms. Patients with sCJD often present with early cognitive and psychiatric manifestations, such as memory loss, irritability, depression, ataxia, extrapyramidal symptoms, and in rarer instances, psychosis. Later symptoms include myoclonus, cortical blindness, seizures, and in its final stage, akinetic mutism. We report a patient ultimately found to have sCJD whose presentation was initially mistaken for an exacerbation of his chronic schizophrenia, delaying his diagnosis.

Who Should Decide? Residence Capacity Evaluation of a Cognitively-Impaired Older Adult Requesting an “Unsafe” Discharge to Home

Abstract Psychiatrists are routinely consulted to determine decisional capacity for elderly patients with cognitive impairment who refuse a safe discharge to a nursing facility and want to return home. The medical team pursuing this discharge plan is often narrowly focused on a patient′s physical safety. Psychiatric consultants should take a holistic view of the discharge options and consider the physical, medical, psychological, social, and emotional risks and benefits of each discharge option. The psychiatrist can then apply the sliding scale of decisional capacity more effectively. This modified capacity evaluation better promotes patient autonomy.

Japanese Psychiatrists' Attitudes toward Patients Wishing to Die in the General Hospital: A Cultural Perspective

In 1961 in Japan, the son of a hospitalized man suffering from severe pain after a stroke mixed a cup of milk with insecticide and arranged for his unsuspecting mother to give this to the patient, who had requested that his son assist him in dying. The son could not endure his fathers condition and killed him in order to show his love.

Psychopathology and psychotherapy in the dying AIDS patient

Abstract AIDS is not yet the problem in Japan that it is in North American, Europe and Africa, but at the recent 10th International AIDS Conference held in Japan, it was estimated that more Asians will become infected with HIV in the coming year than any other population worldwide. Although the majority of these infections will occur in Thailand and India, it was estimated that there may be as many as 15 000 HIV positive individuals in Japan, a number expected to rise to 26 000 over the next 3 years. Although AIDS is arriving in Japan later, this may give society in general and the medical profession in particular, time to learn from the experiences and mistakes of those who had a head start in dealing with the epidemic.