Managing Difficult Behaviors of Clients WithHIV and Personality Disorders: Managing Difficult Behaviors of Clients With HIV 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


With Asymptomatic infection: 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.


With symptomatic illness: 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.


Personality Traits/States Associated with Sexual risk Behaviors for HIV exposure and Transmission: 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


Common Treatment Dilemmas: 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.


Personality Disorders Associated with HIV Risk: Personality Disorders Associated with HIV Risk -Borderline -Antisocial -Histrionic


Antisocial PD: 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


Borderline PD: 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


Histrionic PD: Histrionic PD -Overly emotional -Rapid shifts in affect -Attention seeking -Sexually seductive -Self centered


Treatment of Antisocial PD: 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.


Treatment of Borderline PD: 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


Treatment of Histrionic PD: 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


Medical Management of Unstable PD Patients: 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 .