HIV / AIDS Course > Chapter 3 - Assessment Issues

Chapter 3: Assessment Issues

III. Assessment Issues

In this section we identify the Physical, Social and Emotional/Psychological Assessment Issues of HIV/AIDS.

A. Physical Assessment

1. HIV Testing

The only way a person can find out if they have HIV/AIDS is through an AIDS test. Some of the places to obtain an AIDS test are local Public Health offices, organizations such as Planned Parenthood or at a Doctor's office. There are also home testing kits where a person can take a sample of their blood and then send it to a laboratory to get tested.

Usually people receive a blood test but there are now tests where samples of mouth fluid (not the same as saliva) are taken by scraping the inside of the cheek, and there are also urine tests. The tests look for HIV antibodies. Antibodies are proteins produced by the immune system to fight a specific germ. Test results are usually available within two weeks. There are rapid tests that can return results in 30 minutes, but it is always recommended to have a second test taken.

When an individual is infected by HIV it usually takes between three weeks and two months for the antibodies to show up in a test. There is a small percentage of individuals that will take longer for the antibodies to show up, but after 3-6 month testing should identify any HIV infection in the body.

[QN.No.#. 9. Seroconversion, which usually take place between 6 weeks and 3 months after infection is:]

After testing positive the person should receive their result from a counselor who will tell them what to expect and refer them to resources for health and counseling services and support. A positive test does not mean a person has AIDS and it is important for people to understand that many people live long and healthy lives after being infected with HIV.

2. Diseases / Symptoms Associated with HIV and AIDS

As mentioned previously, HIV itself does not kill a person. It is a virus that wipes out a persons immune system thereby making them susceptible to infections and diseases that a healthy immune system conquers.

It may be likened to the difference of fishing off the side of a boat with a single pole versus using large nets. The fish are all in the water, but the net is going to get a whole lot more of them. In addition, when fishing with a pole it is much easier to identify and throw the unwanted fish back.

There are many diseases out there, but most of us have just a pole. There are a couple of diseases we might catch with that pole (tuberculosis, hepatitis) but there are others we will not catch (Kaposi's Sarcoma). On the other hand, those that are HIV positive have a net, and they are likely to catch any number of infections just from exposure.

[QN.No.#8. Which of the following would not be considered a secondary infection as a result of HIV:]

I know we have already gone over this next list thrice, but four is greater than three so here it is again. Besides, it fits topically in this portion of the course and you probably forgot it anyway, so consider it a refresher.

Because HIV attacks the immune system it leaves the individual susceptible to disease that would otherwise be fought off by a healthy immune system. Aegis (2005) provides the following list of opportunistic infections associated with HIV:


AIDS Dementia Complex (ADC)
Apthous Ulcers
Aspergillosis
Bacillary angiomatosis (cat scratch disease)
Candidiasis (thrush, yeast infection)
Coccidioidomycosis
Cryptococcal Meningitis
Cryptosporidiosis
Cytomegalovirus (CMV)
Histoplasmosis
Hepatitis
Herpes Simplex (HSV, genital herpes)
Herpes Zoster (HZV, shingles)
Human Papiloma Virus (HPV, genital warts, cervical cancer)
Isosporiasis
Kaposi's Sarcoma
Lymphoma --
  1. Systemic Non-Hodgkin's Lymphoma (NHL)
  2. Primary CNS Lymphoma
Malabsorption
Microsporidiosis
Mycobacterium Avium Complex (MAC, MAI)
Molluscum Contagiosum
Oral Hairy Leukoplakia (OHL)
Peripheral Neuropathy
Pneumocystis Carinii Pneumonia (PCP)
Progressive Multifocal Leukoencephalopathy (PML)
Salmonellosis
Syphilis and Neuroshyphilis
Toxoplasmosis
Turberculosis (TB)

3. T-Cells and Viral Load Tests.

The following information is from Project Inform at http://www.projectinform.org/fs/HIVDiagTest.html

After becoming HIV positive it is important for patients to have regular blood work done to monitor the disease. This provides a guide for medical personnel on when to begin different medications in fighting the virus. Two tests used together help provide a clearer picture of the progress of the disease.

T-Cells

The first of these tests is the measurement of the T-cells in the blood. The T-cells are part of the white blood cells that fight off infection. They are called T-cells because they come from an organ called the Thymus. The two types of t-cells looked at are CD4 and CD8 . The following from Project Inform (2005) explains the actions of these two types of cells:

[QN.No.#7. T-cell (CD4 ) test and Viral Loads tests help measure the progress of the disease in the body:]

"T cells are involved in "cell-mediated immunity," when cells themselves (and not antibodies) supervise the killing of infectious particles and cells. Two types of T cells are CD4 (helper) and CD8 (suppressor or cytotoxic) cells. It is well known that HIV causes a slow decline in CD4 cells in most people. Normal CD4 cell counts are 600-1,500 cells per cubic millimeter of blood. Normal CD8 cell counts in an HIV-negative person are 300-800 cells per cubic millimeter of blood."

CD4 used to be the best indicator available in predicting the stage of the disease and the risk of developing AIDS related complications. The test tells us how many cells are present but not if they are functioning well. The T-cell count is a better indicator of when to begin using medications to prevent opportunistic infections. It is also most helpful in looking at the ratio of CD4 cells to CD8 cells. Normally there are two CD4's to every one CD8, but this number changes to two CD8's for every CD4 in the HIV disease.

It is important to note also the T-cells counts can vary to the circumstances under which the test is taken, from the time of the day, to the stress on the patient, to how quickly the test is performed after the blood is taken.

The following list helps define what the different levels of T-cells indicate in regard to the progress of HIV:

What do CD4 cells counts mean?
  • Above 500 CD4 cells
    • No unusual conditions likely. Emphasize good health habits and healthcare maintenance, such as vaccines and nutrition.
  • 200–500 CD4 cells
    • Increased risk for shingles (zoster), thrush (Candida), skin infections, bacterial sinus and lung infections, and TB.
    • Opportunistic infections (such as PCP, MAC and CMV) are rare
  • 50–200 CD4 cells
    • Increased risk for PCP and other opportunistic infections.
    • Preventative treatment for PCP is indicated.
    • If counts are fewer than 100, consider preventive treatment for MAC, CMV and invasive fungal infections.
  • Below 50 CD4 cells
    • Increased risk for opportunistic infections, including MAC and CMV. Continue preventive medication. (Project Inform, 2005)


Viral Load Tests

Viral load, disease progression and anti-HIV therapy.

Viral load is the amount of genetic material of HIV that is in the blood. Viral load levels are a good predictor of the stage of the disease as they measure the amount of HIV and can be an effective tool in examining the effect of medications on the virus. Using the T-cell tests and viral load tests help provide a more complete picture of the progress of the disease. Because the levels of T-cells and viral load can fluctuate so much, it is important to look at the trend of testing rather than one particular test. Higher viral load counts usually means that the patient will have a lower T-cell count and more rapid disease progression.

Viral load also "seems to be a good predictor of long-term outcomes with regard to disease progression and death." (Project Inform, 2005)

Viral load in plasma and other HIV reservoirs.

Because viral load is only measured from the blood, it's important to know if, as HIV levels are reduced in the blood, are levels also being reduced in other parts of the body? A few recent studies show that viral load in the blood correlate with viral load in semen, vaginal secretions and lymph tissue. As viral load decreases in the blood, it also seems to decrease in these less accessible areas of the body. More research needs to focus on the correlation between plasma viral load and HIV levels in the brain and bone marrow:

The following guidelines are provided for interpreting viral loads tests:

Low, stable and decreasing viral load is considered a good thing, and high or increasing level warrant physician attention as they may indicate treatment failure. Viral load below 10.000 copies/ml is generally considered "low." Viral load above 100,000 copies/ml is generally considered "high."

Both tests are important for determining the progress of the HIV virus. T-cells help show past progress of the disease and the viral load level may help predict the direction it is going.


B. Social Issues

When AIDS first came to the public's knowledge in the early 1980's, the amount of accurate information available was limited, but the misinformation, on the other hand, seemed unlimited.People were scared, and while in a later section we will dispel many of the myths associated with AIDS, those myths, along with how the media portrayed the disease, contributed a great deal to the social stigma of AIDS.

[QN.No.#11. When AIDS was first publicized in the United States the general public was:]

Initially, AIDS was considered exclusively a gay disease. In truth, a large portion of the disease in the U.S. has been as a result of sexual contact between gay men (CDC, 2007). Along with the stigma of being gay came a disease that could kill people, and rumors spread that it could be transmitted almost as easily as the common cold. Misinformation still abounds and the social issues that result from having HIV/AIDS are important to assess as a healthcare practitioner providing services for a client with HIV/AIDS and/or their family and friends.

1. The Dilemma of Disclosure

HIV/AIDS is a social repellant. There is still a fear that proximity to a person with HIV/AIDS exposes one to the risk of transmission. Divulging the fact that one is infected can bring rejection from family, friends and other relationships. It can make finding a job more difficult or even cause medical personnel to be hesitant to treat. However, it can be in the best interest of the patient to disclose their disease for health reasons, and social support.

[QN.No.#12. People living with HIV can inform others without fear of reprisal or stigmatism now that everybody understands the disease better:True/False?]

Not all people with HIV disclose their infection, but failure to disclose has potential to harm the self, others, and close relationships. Disclosure of HIV status is crucial for both the individual's health and broader health prevention efforts. (Greene, Derlega, Yep, and Petronio 2)

Needless to say it is difficult for seropositive patients to confide in others that they have the disease. A person who discloses makes themselves vulnerable to attack, ostracism and ridicule (Greene, Derlega, Yep, and Petronio 4).Why risk it? Why not just keep it a secret? In addition to the health reasons, there are the paradoxical social reasons. Whereas there are risks and great potential for negative reactions, which are real and hurtful, there are also potential benefits. In order for a person to be supported by those closest to them, whether it is family members or friends, those people need to have awareness of the diagnosis in order to have a chance to be supportive. The seropositive patient is more than likely going to go through some very emotional turns. They will benefit from somebody and hopefully some-bodies, being there to encourage them on. For this reason, social support is an important part of the seropositive patient's mental and physical health.Good support has been "found to be health-promoting, health-restoring and associated with a decrease in mortality risk" (Sarason & Sarason, 1987). Studies have shown that "individuals with high levels of social support satisfaction were less likely to develop AIDS than those with low levels of social support satisfaction" (Greene, Derlega, Yep, and Petronio 127).

As previously mentioned there are a lot of possible negative results to disclosure and "although reasons for HIV disclosure may be compelling, there are also possible disadvantages (and risks) to the person with HIV and to significant others associated with HIV disclosure" (Derlega, Lovejoy 1998). People who have disclosed being seropositive have reported negative responses to it. (Greene, Derlega, Yep, and Petronio 8)

2. Decline in Intimate Relationships

One of the negative responses is having fewer social relationships.A person may see a large drop off of the relationships rather quickly after revealing to others that they carry the disease, while some of those relationships may fade away gradually. In one study more than half of the patients reported having less contact with others from the point of being diagnosed which they attributed to their HIV status (Green, and Sobo ).

When somebody does disclose their condition they do so with uncertainty as to how others will react with possible unforeseen consequences.Usually the person will disclose with some hope or expectation that the person will be supportive. They may find, however, that confidants are not as engaged as they need them to be (Greene, Derlega, Yep, and Petronio).

As one sister of a man with HIV indicated, "I've not been there for him. I couldn't handle knowing my baby brother was dying, so I just checked out." In this case, the man felt abandoned by the sister's coping behaviors. Thus, it is important to explore helpful social support (Greene, Derlega, Yep, and Petronio 130).

Although there are many who may react negatively to the news of somebody being HIV positive, the negative responses from close friends and family are reported to be the most hurtful and traumatic (Green, and Sobo)

3. Society's Negative View

The following two quotes from HIV-positive individuals express the negative social effects the disease has had on them:

I've had less contact with people since my diagnosis. I've become more reserved with people and I walk about convinced that I have a stamp on my head: "HIV"

The average person is ignorant about HIV like going back to leprosy and people being unclean and people seeing it with panic

(Green, and Sobo 187)

These statements reflect how many HIV positive people feel they are perceived by society. These feelings can exacerbate the negative effects of the disease on the social lives of these individuals. Practitioners should work with patients to prepare them for the possible reactions to disclosing being HIV positive.The practitioner can also serve as a helpful support to the patient if they should decide to disclose and to consider the advantages and disadvantages during the decision-making process.

A patient may want to make disclosures to their friends or family with the practitioner present.This way the practitioner can offer both support to the patient, the persons they are disclosing to, and be there to answer any immediate questions and clear up any myths about the disease. One thing is clear, the more the practitioner can assist with building a positive social support system for the patient, the better their quality of life will be, including their physical health.It will also help the practitioner share the load for the support, lessening the issues of counter-transference burn out.

Following this it is important to discuss and assess with the client these social issues from which they are suffering and how it is affecting them.

Individuals with HIV disease experience many losses: financial, physical, familial, and psychological. These losses may have a direct relationship on the individual's motivation and willingness to follow the prescribed treatment regimen. These losses are also likely to distract the individual from focusing on making all the lifestyle adjustments necessary to adhere to treatment. (Frank and Miramontes, 2005)

A thorough psychosocial assessment will help the healthcare practitioner gather the information necessary to assess the social impact the disease is having on a person.With the tools and resources provided in the treatment section of this course, the social impact of the disease can be treated and help make the disease more socially manageable. This will serve in improving the quality of life for that person, increasing chances of treatment adherence, and lowering the risk of depression and anxiety disorders.

[QN.No.#13. A thorough biospsychosocial assessment of someone who is HIV evaluates the following:]

[QN.No.#14. Why is it important for healthcare professionals to be aware of more than just the physical symptoms of HIV/AIDS?]


The case of Ryan White illustrates how society may react to a person with HIV/AIDS. Ryan was not a gay man or a drug user.In other words, he did not contract the virus through the means that society would consider immoral or as a result of personal behavior choices. Rather, Ryan contracted the disease through a blood transfusion.Ryan's story was well expressed by a 16 year old high school student named Jes (2005):

The Ryan White Story


Above, you see the picture of one of the greatest people to grace this earth, in my opinion. His name is Ryan White and he died with AIDS. His story follows.

On December 6, 1971, Ryan Wayne White was born. Three days later, doctors told his parents that he was a hemophiliac. That means his blood does not clot the way it is suppose to. Luckily, there was a new product out that contained the clotting agents found in blood. This product was called Factor VIII, and was made from blood. Ryan grew up having many hemorrhages, or bleeds, and would get IV's of Factor VIII twice a week.

While he was battling pneumonia, he had to have surgery on December 17, 1984, to have two inches of his left lung removed. Two hours after the surgery, doctors told his mother that he had contracted AIDS. He was given 6 months to live. But he was a fighter.

He was determined to continue at his school and live life normally. But in 1985, not many people knew the truth about AIDS. Not very much was known about AIDS. Ryan faced a lot of discrimination, mostly based on the unknown. His school tried to keep him from attending and the town in which he lived was not very supportive, to say the least.

After legal battles, Ryan and his mother settled with the school to have separate restrooms and disposable silverware from the cafeteria. But that didn't stop much. Students vandalized his locker with the word "FAG" and restaurants threw his dishes away after he left. A bullet was even fired into his home.

After that, he and his family moved to Cicero, Indiana, and were welcomed. People had been educated and Ryan was happy again. He had his learner's permit. He had friends, his family, and he was turning an incurable disease into a way to educate America. There was a movie made about him, titled "The Ryan White Story," that aired on ABC. Ryan got to be an actor as he played his friend Chad.

Ryan White was making a difference. But on April 8, 1990, the world lost a wonderful person. He knew he was famous, took that, and turned it into something that everyone could learn from. He knew his purpose in life.

The professional healthcare practitioner should be aware of the potential social issues that face the client.Helping the client sort through and identify these issues will help in providing a course to strengthen social supports and relationships with individual, groups and the community.Indeed, blame and fear have been related to reduced levels of emotional support provided to HIV-infected men (Collins, 1994). We address the assessment of psychological and emotional issues in the next chapter.


C. Psychological and Emotional Issues

With the advances in medical care for people with HIV/AIDS many people live much longer with the disease. No longer is getting HIV a short term terminal disease. This brings up differing psychological and emotional issues for the infected person. Despite encouraging medical advances, an HIV diagnosis creates significant anxiety and distress about one's health, self-identity and close relationships (e.g., Chesney, Greene, Derlega, Yep, and Petronio).

[QN.No.#19. Despite encouraging medical advances, an HIV diagnosis creates significant anxiety and distress about one's health, self-identity and close relationships:True/False]

The major areas of Psychosocial Stress to be assessed include:

  • Psychological Impact
  • Fear of disease
  • Fear of treatment Failure
  • Impact on quality of life
  • Loss of Control
  • Family Impact
  • Co-existing stressors

We explored many of the stressors associated with physical health and relationship concerns in the previous chapters. This chapter will look at the issues and assessment of psychological and emotional adjustment of those diagnosed with HIV/AIDS. As in the chapters preceding this, the information here will overlap with other chapters as physical and social issues impact on the psychological well being of the individual.

1. Issues of Anxiety and Coping Skills

First, a brief illustration:

Her hands were sweating. She did not understand what was happening to her but thoughts were racing through her mind with unbelievable speed. It was as though a locomotive had been let loose in her head and was running wild. She dimly felt the blood pounding at her temples, surging to break through her skin. Her stomach was writhing, and sweat was pouring down her head. She gasped for breath. "Oh, what it is taking so long?" she thought.

Quickly she reviewed past events in her mind. She had been diagnosed with HIV a lifetime ago--six months on a calendar. "You are HIV-Positive." She knew the doctor had said other things, but she could not remember anything else. The words raced through her head. She had visions of wasting away, shriveled up beyond recognition, alone in a hospital, dying. The next flash saw her being publicly ridiculed on a sidewalk. "Somehow people would find out and would hate me." She forced herself to stop, but the feelings were overwhelming.

"What is taking so long!", she screamed to nobody in particular. She did not realize she had spoken the words aloud until several people in the waiting room looked at her in astonishment. "Are you all right?", a faceless voice asked. She felt her head nod assent, yet she knew she was not all right.The person led her back to a room with bed that she sat down on. She was getting sick and would not be able to help herself.If only she were home, she would know what to do, but waiting in this place left her helpless.

She felt herself beginning to gag and forced herself to stop. She had to gain control of herself. She could not let people see her like this. She told herself for the millionth time, "I feel okay. I am sure the result on my blood test will be okay." The horrible possibilities just kept rushing back. "But what if it isn't? What if they show that my immune system is too weak to fight off those horrible diseases? What if I am going to die soon?" Even as she fought for control, she began to feel her eyes cloud over and the room began to spin. Her nausea got worse and the waiting was unbearable. She felt her head was about to burst. "If only I could breathe!", she thought, and her mind raced. "I can't die, I just can't!"At that moment the door opened and footsteps approached. It was the doctor. "You're test results look good."

(Adapted from Kaplan, 1984)
The reaction somebody has to the news that they are HIV-Positive may depend on the amount of accurate information they have regarding the disease. For example, a rather inaccurate perception may result in the following scenario.

GIGI Nicks didn't have a clue. She had lost enough weight to win compliments, but she wasn't on a diet. Then came the small lumps, first under her armpits and then on her neck.

For six months Nicks visited her doctor until she was finally diagnosed as having the human immunodeficiency virus. She still didn't grasp the significance of her ailment until she asked her girlfriend, 'Exactly what is HIV?'

"She didn't know at first but said she'd call me back," Nicks recalls. "I don't know where she got her information, but she called back and told me: 'GiGi, guess what?? You have AIDS, and you're going to die!'"

At that moment, a little more than two years ago, Nicks came face-to-face with AIDS hysteria. (Lyons, 1992)

Hopefully we are a little more sensitive and prepared to educate clients when they are informed that they have the disease. It would not, however, be appropriate to minimize the seriousness of the disease. The individual needs to know it is serious so that they, in turn, will take their treatment serious. Because of that, there will naturally be a measure of anxiety. Depending on the individual's adjustment to being diagnosed, this anxiety can range from motivating them towards treatment compliance, or debilitating towards non-compliance, poorer health, and exacerbated by depression. Assessing the anxiety of the client and their coping skills is an important component of treatment.

When clients complain of anxiety it means they are worrying about something happening. If this is excessive and occurs over a significant amount of time on most days, the person may have an Anxiety Disorder Due to the Medical Condition of being HIV positive. The anxiety may present itself in general ways such as:

  • Restlessness of feeling keyed up or on edge.
  • Being easily fatigued (although this can be a result of the disease)
  • Difficulty concentrating or mind going blank
  • Irritability
  • Muscle Tension
  • Sleep Disturbance.


Another possibility is the client suffering from Panic Attacks. These attacks are similar to what the woman at the beginning of this section was experiencing.It is more of an intense fear manifested with various physical symptoms like sweating, nausea, fear of dying and a pounding heart.In addition, the person may present obsessions and compulsions as they grasp at some type of control, or obsess over the avoidance of germs (which admittedly would be of a natural greater concern than a non-HIV person). (DSM-IV-TR, 2000)

The practitioner should work not only to assess whether anxiety exists, but the level at which these anxieties are affecting the quality of life of the person.There are different ways to help assess this. Journal keeping can be one tool used to assess and monitor the anxiety of HIV positive clients.It allows them to reflect and write feelings during the week regarding social interactions, physical symptoms and general health, thought processes and general progress.They are useful for monitoring thoughts during social interactions, after doctor visits, regarding treatment compliance or non-compliance, effects of medications and other events.These recorded thoughts and feelings offer the therapist direct access to the client's fears and anxieties about what might go wrong. This information is later helpful when implementing interventions.

In addition to these journal reports, there are also questionnaires and surveys to measure anxiety. These can be developed by the therapist if there are specific anxiety types of behaviors that should be measured, or they can obtain other useful surveys and measures.Their purpose is to measure the degree of anxiety in different situations, times of the day, etc. Repeating the survey during treatment and regular intervals will allow the therapist to see the progress of the client's anxiety.

In addition to determining a diagnosis and understanding the patient's patterns of fear and avoidance and troublesome cognitions, clinicians should gain some appreciation for the context in which the clients' live. It is already a given for our purposes that the client is HIV positive, thereby causing a natural level of anxiety.In addition, however, it is important to remember that the client's identity goes far beyond, and is even separate from, having the disease.There are other things in the client's social life that may contribute to the anxiety.

Mclean and Woody (2001) stated that,

Taking a few moments to get contextual and historical information on the client's experiences with family, intimate relationships, school, and employment will be important in understanding the client's social functioning. The patient's strengths should also be assessed, as these are a source for hopefulness and enjoyment, as well as clues for helping the client to build a social support network. Thus, the clinician should note hobbies, important relationships, appealing personal qualities, and workplace opportunities for socializing.

A correlate to the level of anxiety a person is feeling regarding being HIV positive may be their ability to cope and how they choose to cope. Coping has been defined as "cognitive and behavioral efforts to manage specific external and/or internal demands that are appraised as taxing or exceeding the resources of the person" (Lazarus & Folkman, 1984, p. 141). Coping is generally emotion-focused or focused on problem-solving. (Folkman, Lazarus, Dunkel-Schetter, DeLongis, & Gruen, 1986; Vitaliano, Russo, Carr, Maiuro, & Becker, 1985).

For example, the seropositive patient who is coping by focusing on problem- solving will be actively working on keeping themselves healthy. They will follow the treatment regiment, eat right, exercise appropriately, and feel positive about what they are doing.

On the other hand, clients having difficulty regulating the emotional stressors that come with being seropositive may be using a coping mechanism like avoidance manifested by such behaviors as escapism, wish fulfilling fantasy and emotional expression (Folkman & Lazarus, 1980). Psychological distress is higher in those who use avoidance coping versus those who use active-positive, problem-solving focused forms of coping (Fleishman & Fogel, 1994; Namir, Wolcott, Fawzy, & Alumbaugh, 1990; Wolf et at., 1991).

[QN.No.#20. Because those with HIV/AIDS know they can live longer lives with current medical treatment, depression is no longer a factor for these patients:true/false?]

Psychological stress is greatly affected by the way a person attempts to cope. Just like anxiety, coping can be affected by genetic influences, personality characteristics, external resources and social support. This makes such things as optimism and social support have a strong correlation to coping ability. In the case of HIV, that support and optimism may be severely tested. (Taylor and Aspinwall 1996)

Often negative encounters with others such as arguments, misunderstandings, and inappropriate demands, result in avoidance coping behaviors of isolation, anger and wishful thinking. These in turn have a strong effect on negative mood and further isolation behaviors. This can create a cycle where conflict creates more isolation on the part of the patient, which can create more conflict with others who perceive such behavior as frustrating and antagonizing. These intensify in their cycle and both contribute to a greater level of psychological stress and anxiety for the patient. (Shinn et al., 1984).

As might be deduced, the withdrawal from others by the client has strong effects on mood—reducing positive mood and increasing negative mood towards depression. In one longitudinal study (Lackner et al., 1993), social conflict was positively related to depression measured six months later.

2. Depression

The difference between anxiety and depression is that anxiety is an anticipatory feeling of tension, whereas depression is a feeling of tension associated with the idea that something bad has happened. (Kaplan, 1984)

As with anxiety, there are different scales and surveys used to measure levels of depression. Clinicians should be especially aware and assess for suicidal thoughts and ideation.An HIV patient's cognitions can be a road of depressive thoughts. On that road are stressors, ill health, feelings of helplessness, social rejections and isolation, and the feeling that they are going to die anyway.

The specific symptoms for a major depressive needing to be assessed are laid out in the DSM-IV-TR (2000):

Major Depressive Episode

  • Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure.
    Note: Do not include symptoms that are clearly due to a general medical condition, or mood-incongruent delusions or hallucinations.
    • depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or observation made by others (e.g., appears tearful).
      Note: In children and adolescents, can be irritable mood.
    • markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation made by others)
    • significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. Note: In children, consider failure to make expected weight gains.
    • insomnia or hypersomnia nearly every day
    • psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down)
    • fatigue or loss of energy nearly every day
    • feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick)
    • diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others)
    • recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide
  • The symptoms do not meet criteria for a Mixed Episode (see p.171)
  • The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
  • The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hypothyroidism).
  • The symptoms are not better accounted for by Bereavement i.e., after the loss of a loved one, the symptoms persist for longer than 2 months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation.


D. Case Example

The following are excerpts from an interview conducted with author Andrew Solomon, that illustrates one persons battle with depressions and anxiety related to being HIV positive (Wrestling with the Noonday Demon, 2002):

You said at one point in the book: "I've never in my life felt so temporary."

Yes, there was the feeling that nothing mattered, that nothing was going to last, and that there was no point in doing anything because everything was so transient. There was a complete loss of the sense of purpose that has tended to drive me in life. And so I began after a while to feel less and less interested in doing things. And I would think that I really should make some plans, or should go and see someone, or should go and do something. And then I would decide, "Maybe I just won't bother." And then I began to feel kind of put upon by the ordinary demands of life. I would come home and listen to the messages on my answering machine, and instead of being thrilled to hear from friends, I would think only that this was such a lot of people to have to call back. I could only think of all the time and energy it would take to respond to them all.

And then it began to get worse, and more and more things seemed to require so much effort, to be so difficult, until it got to the point at which I would think about eating, and the idea of getting the food and putting it on a plate and cutting it up and chewing it and swallowing it -- this all began to seem so monumental and so difficult in a way that I had never previously imagined. And I felt as though every step of the day, every little piece of everything I did was just impossible. And so I started doing less and less and less. I stopped eating and became more and more withdrawn -- and then the anxiety set in. And while the depression part of the experience was bad, the anxiety part was intolerable.

At any point in that process were you overwhelmed by a sense, or a fear, of dying? Was that even on the agenda during this terrible time?

Yes, I think I was overwhelmed by the sense that death was imminent. During the worst period of the depression I was not actually acutely suicidal because at that point you don't have the energy or the where-withal to be suicidal. Later on, as I began to recover a little bit, I felt that if I was going to die in the end anyway, I wanted to just do it now and get it over with. When people are depressed they have a mix of responses. There is one set of responses in which one believes things that aren't true, and it is possible to correct those. If you start to believe that no one loves you, someone can respond, "Of course I love you." They can help you understand that. Another part of what goes on in depression is that one's perceptions are distorted. You perceive things that are real, but your feelings about them are very different from what they would be if you were not depressed. For example, there is the realization that no matter what we do, each of us is trapped in an individual human body and will never be able fully to connect with another human being. Or that no matter what you do, in the end you will die. If you're in good spirits, you think, as we all do, "Well, that's the human condition ... now what should we have for lunch?" But in a state of depression, you experience those feelings and you feel like you can't tolerate life because of these basic realities.

I think each of us has had that moment, when you wake at three in the morning and it comes home with such certainty that, in fact, "Yes ... I'm going to die." But, most of the time, people can somehow get around that, just go back to sleep in anticipation of the morning.

Absolutely, and when I'm asked, by people who haven't experienced these feelings, what intense depression and anxiety are like, I say that if you've ever woken up in a little bit of a panic in the middle of the night, then you know what it's like. Imagine a huge extension and deepening of that feeling. That three a.m. panic is when people who aren't depressed come closest to knowing what real depression is.

The Need for an Individual Biopsychosocial Assessment

This section on the assessment of a person with HIV/AIDS has covered the issues of physical, social and psychological/emotional issues related to the disease. Each of these areas are interrelated and often overlap, as does the treatment. Many of the issues that a person infected with HIV may encounter are similar to those others experience that are HIV positive. However, some of the issues are specific to the individual and so it is important that these issues are assessed individually and thoroughly. This well help the development of a treatment plan to be more effective for the patient.



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Question No.7. T-cell (CD4 ) test and Viral Loads tests help measure the progress of the disease in the body:

True
False

Question No.8. Which of the following would not be considered a secondary infection as a result of HIV:

a. Kaposi's Sarcoma
b. Influenza
c. Coccidioidomycosis
d. Pneumocystis Carinii Pneumonia

Question No.9. Seroconversion, which usually take place between 6 weeks and 3 months after infection is:

a. The process by which a person becomes diagnosed with AIDS.
b. Refers to the development of antibodies to HIV.
c. The process by which the body shuts down as a result of the AIDS virus.

Question No.11. When AIDS was first publicized in the United States the general public was:

a. Scared
b. Prejudicial
c.Misinformed
d. All of the above

Question No.12. People living with HIV can inform others without fear of reprisal or stigmatism now that everybody understands the disease better:

True
False

Question No.13. A thorough biospsychosocial assessment of someone who is HIV evaluates the following:

a. Physical symptoms.
b. Effect of the disease on lifestyle and relationships.
c. Effect of disease on mood and emotions.
d.Treatment adherence.
e.All of the above.

Question No.14. Why is it important for healthcare professionals to be aware of more than just the physical symptoms of HIV/AIDS?

a. Psychosocial issues affect nutritional and medical treatment adherence.
b. Psychosocial issues often affect general wellness.
c. It isn’t important
d. Both a and b

Question No.19. Despite encouraging medical advances, an HIV diagnosis creates significant anxiety and distress about one's health, self-identity and close relationships:

True
False

Question No.20. Because those with HIV/AIDS know they can live longer lives with current medical treatment, depression is no longer a factor for these patients:

True
False

 
HIV / AIDS Course > Chapter 3 - Assessment Issues
Page Last Modified On: April 29, 2015, 01:10 PM