1. 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

2. 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.

3. 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.

4. 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

5. 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.

6. Personality Disorders Associated with HIV Risk -Borderline -Antisocial -Histrionic

7. 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

8. 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

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

10. 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.

11. 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

12. 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

13. 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.