Managing Difficult Behaviors of Clients With HIV and Personality Disorders

1. Managing Difficult Behaviors of Clients WithHIV and Personality Disorders Siobhan M. Coomaraswamy, M.D. Columbia University HIV Mental Health Training Project A Local Performance Site of the NY/NJ AETC New York State Psychiatric Institute Director of Education on Character and Substance Use Disorders

2. With Asymptomatic infection • -HIV invades the brain at initial infection • -Neither condition is rare and association may be due to chance • -Not known if HIV by itself increases biological vulnerability to certain mental illnesses.

3. With symptomatic illness • -Concern is differential diagnosis • -Can be a complication of substance use/withdrawal, medical illness, metabolic disturbances, neuropsychiatric manifestations of HIV (e.g.,HAD, MCMD), side effects of HIV-related medications, etc. • -Can occur at the initial presentation of symptomatic HIV illness.

4. Personality Traits/States Associated with Sexual risk Behaviors for HIV exposure and Transmission • -Sensation seeking • -Impulsivity • -Conscientiousness (negatively associated) • -Neuroticism (weakly associated) • -Agreeableness ( negatively associated) • *Hoyle, Fejfar, and Miller, Personality and sexual risk taking: A quantitative review. Journal of Personality,68;6: 1202-31

5. Common Treatment Dilemmas • -Provider counter transference reactions to “self- destructive” and “manipulative” patient behaviors. These patients are the most difficult to manage long term , the paradoxical help seeking chronically help rejecting patient. • -Sensible limit-setting.

6. Personality Disorders Associated with HIV Risk • -Borderline • -Antisocial • -Histrionic

7. Antisocial PD • -Sociopath or psychopath • -Unable to abide by societal rules syntonic with their cultural background. • -Defiant and contemptuous • -Irritable and aggressive • -Frequent or pathological lying • -Reckless disregard for safety of others or self

8. Borderline PD • -Unstable mood/affective lability • -Chaotic interpersonal relationships • -Irritable and anxious • -Fear of abandonment • -Suicidal gestures common • -Sexual promiscuity • --Poor impulse control • -Low frustration tolerance

9. Histrionic PD • -Overly emotional • -Rapid shifts in affect • -Attention seeking • -Sexually seductive • -Self centered

10. Treatment of Antisocial PD • -Treatment is usually court mandated • -Medication for Axis I symptoms • -Hospitalization rarely useful • -Individual psychotherapy is treatment of choice • *Make connections between actions and feelings • *Positively reinforce any emotions but anger and frustration • -Trust is a central issue • -Emphasize immediate and long term consequences of actions.

11. Treatment of Borderline PD • -Challenging to treat but with somewhat better prognosis depending on history and ego strength • -Dialectical Behavioral Therapy(DBT) • *Individual therapy • *Group therapy • *Telephone contact • *Psychiatric consultation and liaison • -Medications for Axis I symptoms • -Hospitalizations • *Transition with day treatment program

12. Treatment of Histrionic PD • -Emotionally needy • -Dramatic presentation of symptoms • -Medication for Axis I Symptoms only • -Self-help groups, family and group therapy not recommended • -Individual psychotherapy incorporating solution focus on short term issues, supportive ego strengthening psychotherapy • -Frequent assessment of suicidal ideation/intent with plan

13. Medical Management of Unstable PD Patients • -Reframe all consequence avoidance so this becomes a reward • -Appeal to the patients cognitive capacities in lieu of mandate or ultimatums which typically result in non productive power struggles and stalemates. • -Treatment plans should be written down clearly and agreed upon collaboratively setting firm limits and realistic goals based on provider resources and mandates .