Case Reports
2. Wilensky AJ. Friel PN. Ojemann LM. et al: Zonisamide in epilepsy: a pilot study. Epilepsia 26:212-220.1985 3. Ito T. Hori M. Masuda Y. et al: 3-sulfamoylmethyl-1.2benzisoxazole, a new type of anticonvulsant drug: electroencephalographic profile. ArzneitmittelJorsch 30: 603-ffl9. 1980 4. Petersdorf BG, Adams RD, Braunwald E, et al (eds): Harrison's Principles ofInternal Medicine. 10th Ed. New York. McGraw-Hili, 1983 5. KUII H, Winters W, Scherman R, et al: Diphenylhydantoin and phenobarbital toxicity. Arch Neurolll :649-656, 1964 6. Hoaken PCS: A case of secondary mania. Psychiatric Journal of the Unil'ersiry ofOttawa 12:47-48. 1987 7. Kranthammer C. Klerman GL: Secondary mania. Arch Gen Psychiatry 35: 1333-1339. 1978 8. Stasiek C. Zetia M: Organic manic disorders. Psychosomatics 26:394-402.1985 9. Matsumoto K, Miyazaki H, Fujii T, et al: Absorption. distribution. and excretion of 3-(sulfamoyl [14Clmethyl)1.2-benzisoxazole (AD-810) in rats. dogs, and monkeys
and of AD-81O in men. Ar:neimittelJorsch 33:961-968. 1983 10. Dodrill CB: Effects of sulthiame upon intellectual, neuropsychological, and social functioning abilities among adult epileptics: comparison with diphenylhydantoin. Epilepsia 16:617-625.1975 II. Liske E, Forster FJ: Clinical evaluation of the anticonvulsant effects of sulthiame. Journal ofNew Drugs 3:32-36, 1963 12. Garland H. Sumner D: Sulthiame in treatment ofepilepsy. Br Med J 1:474-476.1964 13. Gilman AG. Goodman LS (eds): The Pharmacological Basis of TherapeutiCJ. SeI"emh Ed. New York. MacmilIan. 1985 14. Reynolds EH: Schizophrenia-like psychoses of epilepsy and disturbances of folate and vitamin BI2 metabolism induced by anticonvulsant drugs. Br J Psychiatry 113:911-919.1967 15. Maren TH: Relations between structure and biological activity of sulfonamides. Annu Rei" Pharmacal Toxicol 16:309-327.1976
The Psychotic Fear of AIDS ROBERT
L.
FRIERSON.
ear of contracting the acquired immune deficiency syndrome (AIDS) can have many psychiatric manifestations. l -4 As this epidemic grows, individuals outside the traditional risk groups are developing serious psychopathology related to trepidation about contracting the disease. 5- K Depression, obsessive-compulsive behavior, and suicidal ideation have been documented in such individuals, although their concerns about developing AIDS are largely unfounded. 9 . 10 This article describes five patients whose dread of AIDS reached psychotic proportions. All patients tested negatively for AIDS and were without physical stigmata of the disease.
P
Case Reports Patient l. A 22-year-old woman was hospitalized after she began to exhibit bizarre behavior. She had VOLUME 31· NUMBER 2· SPRING 1990
M.D.
undergone kidney transplantation three months earlier and was convinced that she had received contaminated blood during the procedure. She claimed that as a result. she was infected with the human immunodeficiency virus (HIV). On admission to the hospital. the patient received diazepam for agitation. Despite the medication. she required restraints to prevent her from engaging in repeated ablutions. A psychiatric consultation revealed a history of generalized anxiety disorder but no past history of psychosis. The blood and donated organ she received had been screened for HIV antibodies. She had no other risk factors.
Received August 29. 1988; revised April 27. 1989; accepted May 26, 1989. From the Depanment of Psychiatry, University of Louisville School of Medicine. Louisville. Kentucky. Address reprint requests to Dr. Frierson, ConsultationlLiaison Psychiatry. Ambulatory Care Building, 550 South Jackson Street, Louisville. KY 40292. Copyright © 1990 The Academy of Psychosomatic Medicine.
217
Case Reports
Her mood was anxious, and she was paranoid and delusionally convinced that she had AIDS. She refused to allow anyone to touch her. The mental status exam was otherwise normal. The diagnosis was atypical psychosis with obsessive-compulsive features. Computerized tomography (CT) of the head, toxicology screening, and electroencephalogram (EEG) were unremarkable. Negative HIV testing did not allay the patient's fear that she had AIDS. Chlorpromazine therapy was begun and increased to 100 mg every two hours. The patient's anxiety gradually lessened as she became sedated, and the AIDS-related delusions resolved. However, when the dose of chlorpromazine was reduced, she became profoundly depressed and suicidal and was convinced anew that she had AIDS. This patient eventually responded to combined antidepressant and neuroleptic therapy. Patient 2. A 44-year-old woman was evaluated because she feared that her daughter was trying to kill her. Her daughter had been diagnosed with AIDS two months before, and Ms. B. had gradually become quite paranoid regarding her daughter. The patient felt that she would contract AIDS from her daughter, and she had developed auditory hallucinations. Ms. B. had a past history of major depression without psychotic features that had been treated successfully with doxepam. At this evaluation, Ms. B. was anxious, was experiencing hallucinations, and was convinced that her daughter intended to kill her by infecting her with AIDS. Because the patient felt she had to "watch her [daughter] every minute," she had been unable to sleep. Her mental status was otherwise unremarkable, and the organic work-up was negative. Haloperidol 5 mg qid was begun with marked improvement. The final diagnosis was brief reactive psychosis, and AIDS testing 12 weeks later was negative. The patient was instructed about reasonable precautions to observe when caring for her daughter. Patient 3. A 60-year-old man was evaluated after being hospitalized for nausea and anorexia. Although the patient's gastrointestinal work-up was negative, he refused to eat, could not sleep, and was withdrawn. His wife reported that about two months previously the patient became obsessed with AIDS. He had read all the information he could find about the disease and was convinced that he would contract it. He lost interest in other activities and developed the delusion that he was dying of AIDS. He had a history of major depression with psychosis 218
that had been treated successfully with electroconvulsive therapy (ECT). At evaluation, the patient had a blunted affect and psychomotor retardation. When asked why he was hospitalized, he responded "I have AIDS, [and therefore] eating is pointless." His mental status was otherwise normal, and an organic work-up was negative. The diagnosis was major depression, recurrent, with psychotic features. He underwent ECT and had a remarkable improvement in his depression and delusionalthoughts. Patient 4. A 28-year-old homosexual man was admitted to a psychiatric unit because of panic episodes related to his fear of contracting AIDS. Lorazepam was prescribed for panic disorder. HIV testing was negative. The morning after he was admitted, the patient was blatantly psychotic and preoccupied with religion. He stated that he felt the need to "convert" before contracting AIDS. An organic work-up was negative. The diagnosis was atypical psychosis. His symptoms improved following treatment with haloperidol. After treatment, he responded well to education about AIDS. HIV antibody testing six and 14 months later was negative. Patient 5. A 45-year-old woman was evaluated for bizarre behavior that included threatening her husband with a knife, insomnia, and religiosity. After she was admitted to the hospital, she became paranoid and agitated. An organic work-up and HIV testing were negative. When examined, the patient had pressured speech, tangentiality, and auditory hallucinations. The hallucinations were self-deprecatory and prophesied that she would die of AIDS. She had no psychiatric history. The psychiatric diagnosis was acute mania, and she eventually responded to a combination of trifluoperazine and lithium carbonate with resolution of delusional thoughts.
Discussion
The fear of AIDS occasionally occurs in conjunction with a psychotic episode. Whether concern about contracting HIV is a precipitant to psychosis or merely an associated feature is often difficult to ascertain. The patients described in this report developed delusional states following realistic concerns that they would contract AIDS. The most common psychotic features were soPSYCHOSOMATICS
Case Reports
matic and paranoid delusions. Although fear of AIDS was a common theme. each patient incorporated individual. environmental. and societal concerns in his or her delusional system. Psychosis was seen in conjunction with mania. depression. grief. anxiety. and obsessivecompulsive behavior. Such activities as repeated ablutions and religiosity were employed by these patients as they attempted to rid themselves of the disease. When caring for these individuals, the psychiatrist must rule out organic causes of the psychosis and various delirious and demented states. The most important intervention in delusional AIDS is to identify and treat the psychosis. Although initial HIV testing should be performed. unless the patient is at high risk. repeated screening following a negative result is not recom-
mended. It is important to appreciate that patients with psychotic fears of AIDS may be at an increased risk of suicide. Education about HIV infection may decrease the incidence of AIDS-related psychosis. However. after the patients described above had developed delusional thought patterns. they were generally impervious to rational information about AIDS. As patient 2 illustrates. particular attention should be given to the stress on family members caring for AIDS sufferers. The fear of AIDS is growing faster than the epidemic itself. Psychiatrists must recognize the many psychological forms this apprehension can assume if they are to provide effective treatment. Many psychiatric patients are unable to tolerate societal stress and are particularly prone to developing exaggerated fears of AIDS.
References I. Valdiserri E: Fear of AIDS: implications for mental health practice with reference to ego-dystonic homosexuality. Am J Orthopsychiatry 56:634-638. 1986 2. Jenike M: Mosquitoesdon'( wear condoms: when fear of AIDS becomes a disease. Psychiatric Times 4: 1-7.1987 3. Thompson LM: Dealing with AIDS and fear. South Med J 80:228-232. 1987 4. Frierson R. Lippmann S: Psychologic implications of AIDS. Am Fam Physician 35:109-116.1987 5. Jenike M. Pato C: Disabling fear of AIDS responsive to imipramine. PsychoJOmatics 27: 143-144. 1986 6. Miller D. Green J. Farmer R. et al: A "pseudo-AIDS"
VOLUME 31· NUMBER 2· SPRING 1990
syndrome following from fear of AIDS. Br J Psychiatry 146:550--551. 1985 7. SchwartzR: AIDS panic. PsychiatricNelt's Aug 17. 1983. pp7-11 8. Freed E: AID-o-phobia (ltr). Mt'd J Aust 2:479. 1983 9. Miller D: The worried well. in Mana!iement of AIDS Patients. London. Macmillan. 1986. pp 169-173 10. Forstein M: AIDS anxiety and the worried well. in Nichols SE. Ostrow DG (eds): Psychiatric Implications ofthe Acquired Immune Deficiency Syndrome. Washington. DC. American Psychiatric Press. 1984. pp 49-60
219
2. Wilensky AJ. Friel PN. Ojemann LM. et al: Zonisamide in epilepsy: a pilot study. Epilepsia 26:212-220.1985 3. Ito T. Hori M. Masuda Y. et al: 3-sulfamoylmethyl-1.2benzisoxazole, a new type of anticonvulsant drug: electroencephalographic profile. ArzneitmittelJorsch 30: 603-ffl9. 1980 4. Petersdorf BG, Adams RD, Braunwald E, et al (eds): Harrison's Principles ofInternal Medicine. 10th Ed. New York. McGraw-Hili, 1983 5. KUII H, Winters W, Scherman R, et al: Diphenylhydantoin and phenobarbital toxicity. Arch Neurolll :649-656, 1964 6. Hoaken PCS: A case of secondary mania. Psychiatric Journal of the Unil'ersiry ofOttawa 12:47-48. 1987 7. Kranthammer C. Klerman GL: Secondary mania. Arch Gen Psychiatry 35: 1333-1339. 1978 8. Stasiek C. Zetia M: Organic manic disorders. Psychosomatics 26:394-402.1985 9. Matsumoto K, Miyazaki H, Fujii T, et al: Absorption. distribution. and excretion of 3-(sulfamoyl [14Clmethyl)1.2-benzisoxazole (AD-810) in rats. dogs, and monkeys
and of AD-81O in men. Ar:neimittelJorsch 33:961-968. 1983 10. Dodrill CB: Effects of sulthiame upon intellectual, neuropsychological, and social functioning abilities among adult epileptics: comparison with diphenylhydantoin. Epilepsia 16:617-625.1975 II. Liske E, Forster FJ: Clinical evaluation of the anticonvulsant effects of sulthiame. Journal ofNew Drugs 3:32-36, 1963 12. Garland H. Sumner D: Sulthiame in treatment ofepilepsy. Br Med J 1:474-476.1964 13. Gilman AG. Goodman LS (eds): The Pharmacological Basis of TherapeutiCJ. SeI"emh Ed. New York. MacmilIan. 1985 14. Reynolds EH: Schizophrenia-like psychoses of epilepsy and disturbances of folate and vitamin BI2 metabolism induced by anticonvulsant drugs. Br J Psychiatry 113:911-919.1967 15. Maren TH: Relations between structure and biological activity of sulfonamides. Annu Rei" Pharmacal Toxicol 16:309-327.1976
The Psychotic Fear of AIDS ROBERT
L.
FRIERSON.
ear of contracting the acquired immune deficiency syndrome (AIDS) can have many psychiatric manifestations. l -4 As this epidemic grows, individuals outside the traditional risk groups are developing serious psychopathology related to trepidation about contracting the disease. 5- K Depression, obsessive-compulsive behavior, and suicidal ideation have been documented in such individuals, although their concerns about developing AIDS are largely unfounded. 9 . 10 This article describes five patients whose dread of AIDS reached psychotic proportions. All patients tested negatively for AIDS and were without physical stigmata of the disease.
P
Case Reports Patient l. A 22-year-old woman was hospitalized after she began to exhibit bizarre behavior. She had VOLUME 31· NUMBER 2· SPRING 1990
M.D.
undergone kidney transplantation three months earlier and was convinced that she had received contaminated blood during the procedure. She claimed that as a result. she was infected with the human immunodeficiency virus (HIV). On admission to the hospital. the patient received diazepam for agitation. Despite the medication. she required restraints to prevent her from engaging in repeated ablutions. A psychiatric consultation revealed a history of generalized anxiety disorder but no past history of psychosis. The blood and donated organ she received had been screened for HIV antibodies. She had no other risk factors.
Received August 29. 1988; revised April 27. 1989; accepted May 26, 1989. From the Depanment of Psychiatry, University of Louisville School of Medicine. Louisville. Kentucky. Address reprint requests to Dr. Frierson, ConsultationlLiaison Psychiatry. Ambulatory Care Building, 550 South Jackson Street, Louisville. KY 40292. Copyright © 1990 The Academy of Psychosomatic Medicine.
217
Case Reports
Her mood was anxious, and she was paranoid and delusionally convinced that she had AIDS. She refused to allow anyone to touch her. The mental status exam was otherwise normal. The diagnosis was atypical psychosis with obsessive-compulsive features. Computerized tomography (CT) of the head, toxicology screening, and electroencephalogram (EEG) were unremarkable. Negative HIV testing did not allay the patient's fear that she had AIDS. Chlorpromazine therapy was begun and increased to 100 mg every two hours. The patient's anxiety gradually lessened as she became sedated, and the AIDS-related delusions resolved. However, when the dose of chlorpromazine was reduced, she became profoundly depressed and suicidal and was convinced anew that she had AIDS. This patient eventually responded to combined antidepressant and neuroleptic therapy. Patient 2. A 44-year-old woman was evaluated because she feared that her daughter was trying to kill her. Her daughter had been diagnosed with AIDS two months before, and Ms. B. had gradually become quite paranoid regarding her daughter. The patient felt that she would contract AIDS from her daughter, and she had developed auditory hallucinations. Ms. B. had a past history of major depression without psychotic features that had been treated successfully with doxepam. At this evaluation, Ms. B. was anxious, was experiencing hallucinations, and was convinced that her daughter intended to kill her by infecting her with AIDS. Because the patient felt she had to "watch her [daughter] every minute," she had been unable to sleep. Her mental status was otherwise unremarkable, and the organic work-up was negative. Haloperidol 5 mg qid was begun with marked improvement. The final diagnosis was brief reactive psychosis, and AIDS testing 12 weeks later was negative. The patient was instructed about reasonable precautions to observe when caring for her daughter. Patient 3. A 60-year-old man was evaluated after being hospitalized for nausea and anorexia. Although the patient's gastrointestinal work-up was negative, he refused to eat, could not sleep, and was withdrawn. His wife reported that about two months previously the patient became obsessed with AIDS. He had read all the information he could find about the disease and was convinced that he would contract it. He lost interest in other activities and developed the delusion that he was dying of AIDS. He had a history of major depression with psychosis 218
that had been treated successfully with electroconvulsive therapy (ECT). At evaluation, the patient had a blunted affect and psychomotor retardation. When asked why he was hospitalized, he responded "I have AIDS, [and therefore] eating is pointless." His mental status was otherwise normal, and an organic work-up was negative. The diagnosis was major depression, recurrent, with psychotic features. He underwent ECT and had a remarkable improvement in his depression and delusionalthoughts. Patient 4. A 28-year-old homosexual man was admitted to a psychiatric unit because of panic episodes related to his fear of contracting AIDS. Lorazepam was prescribed for panic disorder. HIV testing was negative. The morning after he was admitted, the patient was blatantly psychotic and preoccupied with religion. He stated that he felt the need to "convert" before contracting AIDS. An organic work-up was negative. The diagnosis was atypical psychosis. His symptoms improved following treatment with haloperidol. After treatment, he responded well to education about AIDS. HIV antibody testing six and 14 months later was negative. Patient 5. A 45-year-old woman was evaluated for bizarre behavior that included threatening her husband with a knife, insomnia, and religiosity. After she was admitted to the hospital, she became paranoid and agitated. An organic work-up and HIV testing were negative. When examined, the patient had pressured speech, tangentiality, and auditory hallucinations. The hallucinations were self-deprecatory and prophesied that she would die of AIDS. She had no psychiatric history. The psychiatric diagnosis was acute mania, and she eventually responded to a combination of trifluoperazine and lithium carbonate with resolution of delusional thoughts.
Discussion
The fear of AIDS occasionally occurs in conjunction with a psychotic episode. Whether concern about contracting HIV is a precipitant to psychosis or merely an associated feature is often difficult to ascertain. The patients described in this report developed delusional states following realistic concerns that they would contract AIDS. The most common psychotic features were soPSYCHOSOMATICS
Case Reports
matic and paranoid delusions. Although fear of AIDS was a common theme. each patient incorporated individual. environmental. and societal concerns in his or her delusional system. Psychosis was seen in conjunction with mania. depression. grief. anxiety. and obsessivecompulsive behavior. Such activities as repeated ablutions and religiosity were employed by these patients as they attempted to rid themselves of the disease. When caring for these individuals, the psychiatrist must rule out organic causes of the psychosis and various delirious and demented states. The most important intervention in delusional AIDS is to identify and treat the psychosis. Although initial HIV testing should be performed. unless the patient is at high risk. repeated screening following a negative result is not recom-
mended. It is important to appreciate that patients with psychotic fears of AIDS may be at an increased risk of suicide. Education about HIV infection may decrease the incidence of AIDS-related psychosis. However. after the patients described above had developed delusional thought patterns. they were generally impervious to rational information about AIDS. As patient 2 illustrates. particular attention should be given to the stress on family members caring for AIDS sufferers. The fear of AIDS is growing faster than the epidemic itself. Psychiatrists must recognize the many psychological forms this apprehension can assume if they are to provide effective treatment. Many psychiatric patients are unable to tolerate societal stress and are particularly prone to developing exaggerated fears of AIDS.
References I. Valdiserri E: Fear of AIDS: implications for mental health practice with reference to ego-dystonic homosexuality. Am J Orthopsychiatry 56:634-638. 1986 2. Jenike M: Mosquitoesdon'( wear condoms: when fear of AIDS becomes a disease. Psychiatric Times 4: 1-7.1987 3. Thompson LM: Dealing with AIDS and fear. South Med J 80:228-232. 1987 4. Frierson R. Lippmann S: Psychologic implications of AIDS. Am Fam Physician 35:109-116.1987 5. Jenike M. Pato C: Disabling fear of AIDS responsive to imipramine. PsychoJOmatics 27: 143-144. 1986 6. Miller D. Green J. Farmer R. et al: A "pseudo-AIDS"
VOLUME 31· NUMBER 2· SPRING 1990
syndrome following from fear of AIDS. Br J Psychiatry 146:550--551. 1985 7. SchwartzR: AIDS panic. PsychiatricNelt's Aug 17. 1983. pp7-11 8. Freed E: AID-o-phobia (ltr). Mt'd J Aust 2:479. 1983 9. Miller D: The worried well. in Mana!iement of AIDS Patients. London. Macmillan. 1986. pp 169-173 10. Forstein M: AIDS anxiety and the worried well. in Nichols SE. Ostrow DG (eds): Psychiatric Implications ofthe Acquired Immune Deficiency Syndrome. Washington. DC. American Psychiatric Press. 1984. pp 49-60
219
