NEUROPSYCHIATRIC EFFECTS IN AIDS

A wide range of mental status changes has been attributed directly or indirectly to HIV. Several recent studies have shown that asymptomatic people with HIV do not have deficits in cognitive or physical skills when compared to control groups without HIV. Some instances of disorientation, short-term memory loss, diminished motor coordination and withdrawal or personality changes can be symptoms related to HIV disease, and all are potentially treatable given an accurate diagnosis.

Joyce Seiko Kobayashi, M. D., addressed the neuropsychiatric aspects of AIDS at the Fifth Annual Rocky Mountain Regional Conference on AIDS, February 2-3 in Denver. Using a tree-like graph to rule out unlikely causes for a given symptom in order to isolate the source of the problem, Dr. Kobayashi distinguished several symptom categories to consider -- depressed emotional frames of mind, delirium episodes from acute illness or drug reactions, AIDS-related dementia, and opportunistic tumors or infections in the central nervous system.

Depression in people with or without HIV can be an appropriate reaction to anxiety surrounding a health crisis, or grief for the loss of lovers and friends, or fears of powerlessness over the future. Dr. Kobayashi facilitates discussion groups for HIV positive people to deal with these emotions and seek solutions with the validation of peers.

Mental status changes resulting not from social but from organic reasons may be imminently life-threatening, and should be diagnosed and treated as soon as possible. These include cryptococcal meningitis (see AIDS TREATMENT NEWS #49 and 96); encephalitis or swelling of the brain due to toxoplasmosis (issue #79), herpes or CMV (issues #94 and 95); or lesions in the central nervous system including PML (issue #88), KS (issues #73, 75, and 87) or lymphoma (issue #93).

Cognitive problems which are not a result of opportunistic tumors or infections, but from direct HIV invasion of the central nervous system, are defined as "dementia," or AIDS Dementia Complex (ADC). One theory suggests that HIV damages microglial cells in the brain. Unlike neurons, which are the irreplaceable reservoirs of memory and consciousness, microglial cells function primarily as connections between neurons and can regenerate if the source of their destruction is controlled. A different theory says that HIV-infected cells produce toxins which cause the dementia. AZT, proven to cross the barrier between the bloodstream and the central nervous system, can reverse the dementia caused by HIV, although the new, reduced doses might not be sufficient. Dextroamphetamine and Ritalin are also used to treat mental effects of HIV.

In addition to depression, organic diseases and dementia, some transient mental states are considered a "delirium." Sideeffects of some toxic drug reactions, as well as prolonged, high fevers, can alter lucidity and lead to a delirium. Because many of these symptoms and their origins may mimic or overlap each other, Dr. Kobayashi noted that reliance on an AIDS- knowledgeable physician is crucial for determining a diagnosis and therapy.

A doctor who is unfamiliar with a newly symptomatic patient or current HIV care may not accurately distinguish whether memory gaps and lethargy are stemming from demoralization or a rapidly progressing brain infection, whether an apparent motor control deficit is due to cerebral KS lesions or a recent change in medications, or whether Xanax or a new living situation are in order for a long-depressed person. Mutual trust developed between an HIV-experienced physician and an HIV- positive patient can offer each a background familiarity from which to weigh confusing situations.

For an audiotape of Dr. Kobayashi's presentation, call "Sounds True," 303/449-6229. The tape number for her presentation is AP-27.