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Psychological Features of Illness and Recovery Patterns in HIV Disease PHASE, Canadian Psychological Association and Health Canada Module Developed by Paul C. Veilleux, Ph.D. UHRESS - Centre Hospitalier de l’Université de Montréal Montreal, Quebec.

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Psychological Features of Illness and Recovery Patterns in HIV DiseasePHASE, Canadian Psychological Association and Health CanadaModule Developed by Paul C. Veilleux, Ph.D. UHRESS - Centre Hospitalier de l’Université de MontréalMontreal, Quebec

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The fourth stage of HIV infection, diagnosed when serious opportunistic disease or a CD4 cell count of less than 200 occurs, is commonly referred to as AIDS. Treatment at this stage includes both continuation or enhancement of antiretroviral therapy and the prophylaxis, diagnosis and treatment of specific opportunistic diseases as they occur.Aids

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common hiv related opportunistic infections
CD4 > 500

Lymphadenopathy

Recurrent vaginal candidiasis

Common HIV-Related Opportunistic Infections

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common hiv related opportunistic infections4
CD4: 200 - 500

Pneumoccocal pneumonia

Pulmonary tuberculosis

Herpes

Oral candidiasis

Common HIV-Related Opportunistic Infections

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common hiv related opportunistic infections5
CD4: 200 - 500

Cervical neoplasia

Anemia

Kaposi’s sarcoma

Non-Hodgkin’s lymphoma

Common HIV-Related Opportunistic Infections

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common hiv related opportunistic infections6
CD4 < 200

Pneumocystis carinii pneumonia (PCP)

Mycobacterium avium intracellulare (MAI)

Cytomegalovirus (CMV- retinitis)

Lymphoma

Common HIV-Related Opportunistic Infections

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common hiv related opportunistic infections7
CD4 < 200

Toxoplasmosis

Progressive multifocal leukoencephalopathy (PML)

AIDS dementia complex

Common HIV-Related Opportunistic Infections

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neuropsychological and neuropsychiatric effects of medications used in hiv disease
AZT (antiretroviral)

Headache, feeling ill, asthenia, insomnia, unusually vivid dreams, restlessness, severe agitation, mania, auditory hallucinations, confusion

Headache, asthenia, feeling ill, confusion, depression, seizures, excitability, anxiety, mania, early awakening, insomnia

Neuropsychological and Neuropsychiatric Effects of Medications Used in HIV Disease

d4T (antiretroviral)

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neuropsychological and neuropsychiatric effects of medications used in hiv disease9
Ddc (antiretroviral)

Headache, confusion, impaired concentration, somnolence, asthenia, depression, seizures, peripheral neuropathy

Nervousness, anxiety, confusion, seizures, insomnia, peripheral neuropathy, pain

Insomnia, mania

Neuropsychological and Neuropsychiatric Effects of Medications Used in HIV Disease

ddI (antiretroviral)

3TC (antiretrovirale)

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neuropsychological and neuropsychiatric effects of medications used in hiv disease10
Acyclovir (herpes encephalitis)

Visual hallucinations, depersonalization, tearfulness, confusion, hyperesthesia, thought insertion, insomnia

Delirium, peripheral neuropathy, diplopia

Paresthesias, seizures, headache, irritability, hallucinations, confusion

Neuropsychological and Neuropsychiatric Effects of Medications Used in HIV Disease

Amphotericin B (cryptococcosis)

Foscarnet (Cytomegalovirus)

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neuropsychological and neuropsychiatric effects of medications used in hiv disease11
B-lactam antibiotics (infections)

Confusion, paranoia, hallucinations, mania, coma

Depression, loss of appetite, insomnia, apathy

Psychosis, somnolence, depression, confusion, tremor, vertigo, paresis, seizures, dysathria

Neuropsychological and Neuropsychiatric Effects of Medications Used in HIV Disease

Co-trimoxazole (PCP)

Cycloserine (tuberculosis)

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neuropsychological and neuropsychiatric effects of medications used in hiv disease12
Interferon (Kaposi’s sarcoma)

Depression, weakness, headache, myalgias, confusion

Confusion, anxiety, lability, hallucinations

etc.

Neuropsychological and Neuropsychiatric Effects of Medications Used in HIV Disease

Pentamidine (PCP)

etc.

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events that may trigger crises
HIV testing

HIV diagnosis

Fear of disclosure

Viral load & T4 count

Concerns about negotiating safer sex and/or needle use

First opportunistic infection

First hospitalization

Treatment failure

Leaving one’s job

Moving into a hospice

Confronting losses

Anticipating death

etc.

Events That May Trigger Crises

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losses and transformations facing persons living with hiv aids
Physical capacities

Mental faculties

Body image, dignity

Income, Job, status

Independence, Ano-nymity

Mobility, Recreation

Family, friends

Love and intimacy

Sense of self and one’s role in the world

Anticipation, Control over the future

Sense of invulnerabil-ity and immortality

Losses and Transformations Facing Persons Living with HIV/Aids

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major stressors facing persons living with hiv aids
Job loss, financial insecurity and medical expenses

Informing others about the diagnosis

Fear of loss of body functions and/or of physical disability

Fear of loss of mental functions and autonomy

Changes in body image and self-image

Major Stressors Facing Persons Living with HIV/Aids

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major stressors facing persons living with hiv aids16
Loss of control over one's life

Loss of one’s home

Apprehension of social isolation as death approaches

Major Stressors Facing Persons Living with HIV/Aids

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managing chronic health problems
Assessing anxiety, depression, neuropsychological symptoms, and the need for intervention

Organizing support services

Educating and organizing family, friends, and partners about one's changing needs

Managing Chronic Health Problems

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managing chronic health problems18
Learning to set flexible goals to accommodate changes in energy and health status

Weighing medical treatment needs against quality of life issues

Dealing with anticipatory grief in self and others

Determining what is worth the effort and what is not

Managing Chronic Health Problems

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Processes related to getting well again (new antiretroviral therapy)

Multiples losses

Deinvestment

Reinvestment or

deinvestment

?

Ambivalence

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Reinvestment?

Intimate relationships

Social involvement

Desire to have a child

Return to work

Return to school

etc.

For how long ???

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Returning to Work: Positive Consequences

  • Quality of life
  • Self-confidence
  • Personal and social self-actualization
  • Economic status
  • Independence

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Returning to Work: Negative Consequences

  • Anxiety
  • Medication (cost, side effects, regimen)
  • Difficulty finding a place in the job market
  • Confronting the social network
  • Lost of benefits (insurance, long-term disability plan, etc.)
  • Uncertainty about how long one will stay working

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grief issues in therapy
You can't fix grief – what’s lost is lost.

Allow depression and sadness – don't try to take them away.

Sit with the client and witness the tough feelings.

It's hard to be helpless – both for the client and for the therapist.

Grief Issues in Therapy

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grief issues in therapy25
Just listening is often the best intervention – sometimes you don't have to do or say anything.

Continually give clients permission and encouragement to grieve.

Clients feel safest to grieve when they know their grief can be expressed and contained.

Grief Issues in Therapy

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facilitating the grief process
Actualize the loss through talking and rituals.

Encourage the expression of feelings.

Assist in developing skills for living without the deceased.

Facilitate emotional removal.

Facilitating the Grief Process

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facilitating the grief process27
Encourage specific times for grieving.

Normalize grieving behaviour.

Allow for individual and cultural differences in grieving.

Identify non-productive coping and pathological grieving.

Facilitating the Grief Process

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case study instructions for participants
Form discussion groups of about five participants. Choose a case example that you wish to discuss and answer the four questions shown. Name a spokesperson who will give a summary of your responses or ideas. You will have approximately 30 minutes to discuss and then you will share your ideas with the rest of the class. Case Study: Instructions for Participants

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case study questions
Read the case examples, choose one case, and answer the following questions:

1. What are the feelings and emotions of the patient or client?

2. What are your feelings and emotions regarding this person and situation?

3. What are the needs of the patient or client?

4. What solutions or strategies would you suggest?

Case Study: Questions

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marie
Marie has known that she is HIV+ for seven years. She is hospitalized for the first time with a PCP. The physician also discovered a lymphoma for which she will receive chemotherapy. She is exhausted because she had kept on working until this hospitalization. She is a single mother of a 5-year-old son named Antoine. He is HIV-. Marie's mother is taking care of him during the hospitalization. Marie has never told Antoine about her seropositivity or illness. She is anxious to tell him about her health problems and doesn't know how to do it. She is afraid that she might have to quit her job. She is also afraid of dying. She feels in a panic. You are called on to help her.Marie

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slide31
John is a young IDU. He is a prostitute. He has experienced periods of incarceration because of his work. He is well known by the emergency room staff. Some members of the team have pity for him while others are hostile toward him. He is presently hospitalized for a skin problem related to his drug use. He has also a PCP. He should be hospitalized for two weeks. After a few days, he receives his welfare cheque and asks for a few hours’ leave. The staff is concerned because this type of client frequently does not come back. The staff requires your help in this situation. John

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claire
Claire is a 30-year-old black woman from the Caribbean. Her husband died two years ago from AIDS. She was expecting herself to die in the year following her husband’s death since her CD4 count was below 50 and she had had several opportunistic infections. She spent almost all her savings and is now receiving welfare. With the new treatment, her CD4 count is up to 200 and she has an undetectable viral load. She is afraid of going on with her life (maybe meeting someone else, having a baby, getting a job) because she feels that it would be a betrayal of her husband. She is asking for help.Claire

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jacques
Jacques is André's lover. André has been at the AIDS stage for two years; Jacques is HIV-negative. They have been living together for the last 12 years. Jacques, a high school teacher, is responsible for the housekeeping and André's medical visits, etc. André is blind as a result of CMV retinitis. Jacques expected André to die in the last year but with the new treatment André is still alive. He comes to you because he is exhausted from taking care of André, and he feels guilty when he thinks that André's death would be an easy solution to his problem. He ask for help. Jacques

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peter
You have been following Peter in psychotherapy for almost two years. In the past six months, he has been receiving treatment for CMV retinitis. He has lost his sight in his right eye and his left eye is affected. On a cloudy day, he comes to your office. You notice that his vision is worse because he has to feel with his hands for where objects are. Peter is proud and strongly values. With tears in his eyes, he says he would prefer death to blindness. How can you help him ?Peter

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exercise daily medication schedule
Choose a sample daily medication schedule that a person with HIV may be taking (examples follows). Using yourself and your typical daily schedule (at work, home, or here today), map out your day’s medication regimen, integrating it with meals and other daily activities.Exercise: Daily Medication Schedule

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exercise daily medication schedule questions for small group discussion
What are some possible challenges to following your medication schedule?

What are your emotional reactions to this schedule?

How likely would you be to follow your schedule as instructed?

Exercise: Daily Medication ScheduleQuestions for Small Group Discussion

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exercise daily medication schedule questions for small group discussion37
How would you follow your schedule if you:

were visually impaired ?

were depressed ?

were homeless ?

didn’t want anyone to know you were HIV+ ?

were cognitively impaired ?

What could help you to better follow your medication schedule ?

Exercise: Daily Medication ScheduleQuestions for Small Group Discussion

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exercise daily medication schedule example 1
AZT: three pills (3X100mg) two times a day taken with food

3TC: one pill (150 mg) twice a day, can be taken with food

Crixivan: two pills (2X400mg) every 8 hours around the clock, with water, skim milk, juice, coffee, or tea; one hour before or two hours after a meal; drink a minimum of 1.5 litres (preferably water) throughout the day, store at room temperature, keep dry

Exercise: Daily Medication Schedule: Example 1

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exercise daily medication schedule example 2
Nelfinavir: five pills (5x250mg) twice a day, with a meal

Saquinavir: five pills (5X200mg) twice a day, with a meal

ddI: two pills (2x100mg) twice a day, 30 minutes before or 2 hours after meals

d4T: one pill (40mg) twice a day; can be taken with food

Exercise: Daily Medication Schedule: Example 2

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exercise daily medication schedule example 3
Indinavir: two pills (2x400mg) twice a day with a meal

Ritonavir: 5ml; 400mg twice a day; tastes awful

ddI: two pills (2x100mg) twice a day; must be taken one hour before or after the indinavir and the ritonavir

Hydoxyurie: one pill (500mg) twice a day; can be taken with food

Septra: one pill (5mg) once a day, without food if possible

Exercise: Daily Medication Schedule: Example 3

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psychosocial issues around aids and late hiv disease
Coping with life as a person with AIDS

Managing chronic health problems

Time issues and life issues

Preparing to die

Psychosocial Issues Around AIDS and Late HIV-Disease

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the psychologist s role in medical treatment
Explore how symptoms, diagnostic procedures, medications and treatment procedures affect daily living and one’s sense of self.

Assist the client in formulating questions for his or her physician.

Offer emotional support and suggest ways of establishing a sense of control whenever possible.

The Psychologist’s Role in Medical Treatment

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the psychologist s role in medical treatment43
Teach relaxation and pain management techniques.

Educate clients and significant others about neuropsychological complications and strategies for managing them.

The Psychologist’s Role in Medical Treatment

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psychotherapeutic framework
Client-centred

Team approach

Flexibility (acknowledge ignorance)

System negotiation

Constant interplay between management and meaning

Psychotherapeutic Framework

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maintaining boundaries and avoiding burnout
Tell clients how often, where and when you will see them. Tell them early on in the therapeutic relationship.

Continually review the new commitments you make in light of how many HIV-infected clients you are seeing at various stages of the disease.

Maintaining Boundaries and Avoiding Burnout

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maintaining boundaries and avoiding burnout46
Anticipate the emerging needs of clients and assess services before those needs become desperate.

Know the resources in your community and how to use them.

Maintaining Boundaries and Avoiding Burnout

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