The Clinical Guide to Supportive and Palliative Care for HIV/AIDS

A Clinical Guide to Supportive and Palliative Care for HIV/AIDS • Chapter 10: Psychiatric Problemsare antisocial personality, narcissistic personality, borderline personality and histrionic personality.These disorders tend to create difficulty for patients in relationships with providers, whereasother personality disorders, such as avoidant or passive patients, may elicit provider feelings ofnot being26ablepicasto do enough to engage patients in ongoing treatment.Problematic character traits are distinguished from serious character disorders by the consistencyand intractability of the behavior regardless of the external environment. Many patientsmay exhibit some traits that seem to be components of their basic personality, but are evidentonly under extreme duress. Patients with cognitive impairment who are frightened and havingtrouble completing automatic tasks, patients in pain, and patients intoxicated or withdrawingfrom either substances of abuse or prescribed medications are particularly at risk for exhibitingproblematic behavior which usually resolves when the underlying problem is adequately addressed.Social stressors that often complicate treatment relationships include homelessnessor unstable living situations, unstable support systems, rejection from families of origin, andrelapsing criminal or drug related behaviors.A provider’s reactions to a patient’s character pathology may include anger, fantasies of abandoningor withdrawing care, impulses to limit access to the provider, or frank fear of encounterswith the patient. These emotional reactions to a patient should alert the provider to the likelihoodthat the patient may have a difficult character disorder.While each type of character disorder has particular defense mechanisms, most employ denial(the inability to acknowledge or believe something; e.g., “I can’t infect others because I reallydon’t have HIV”), projection (putting onto others what one is feeling or believing; e.g., “you musthate me”), and splitting (telling different things to different providers with the hope of confusingeach provider or getting one provider to believe that another is being unjust, uncaring orincompetent). Lying, or confabulating, to acquire, for example, increased pain medication, iscommon. The fear of abandonment often provokes in the patient an increased neediness andunwillingness to admit any improvement for fear the provider may withdraw or decrease thelevel of involvement. Projective identification (feeling what a patient is feeling) often leadsproviders to think something is wrong with themselves, instead of identifying the problem as aprojection onto them by a patient.People with character disorders are also vulnerable to psychotic, mood, and anxiety disorders,and have rates of substance abuse at least comparable to the general population. Providersoften may find that granting requests made by such patients provokes a sense of being abused.Errors in treatment can follow from either withholding appropriate treatment or overgratifyinga request in order to end more quickly an encounter with the patient.XCommunication with Other Providers in Personality DisorderUnless there is constant communication among members of the palliative care team, a patient’ssplitting will wreak havoc on the team’s effectiveness. When a patient states something about amember of the team to another member (reporting what was said or done), confirmation isimperative. The provider should never rely on the patient to convey information.While no specific psychotherapeutic technique has been shown to be effective in treatingpersonality disorders in HIV, some clinical guidelines may be helpful; see Table 10-27. Otherpsychiatric syndromes may be present along with personality disorders and should be treatedappropriately.U.S. Department of Health and Human Services • Health Resources and Services Administration • HIV/AIDS Bureau 243