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Excerpt
AIDS, HIV, and Mental Health.
Michael B. King, Cambridge, UK, Cambridge University Press, 1993, 197 pp.
Of the several books to date on psychiatric/psychological aspects of HIV/AIDS (excluding others on risk behaviors and sociocultural factors), this nicely slim British volume by Michael B. King of the psychiatry faculty of the Royal Free Hospital School of Medicine (London) appears to this reviewer to be the best to date, only in part because of its relatively recent publication. (All books on psychosocial and medical aspects of this fast-moving, epidemiologically changing, pathophysiologically complex, heavily researched disease have a short half-life of usefulness.) Dr. King's book, more so than edited volumes, is well-integrated as well as relatively comprehensive. It contains a wealth of references, albeit with some valuable ones inevitably overlooked, in spite of the fact that most of the psychiatric/psychological literature in the field has appeared in U.S. journals. Particularly laudatory are the last three chapters on topics of great importance: problems of health professionals, including attitudes towards homosexuality and drug abuse; problems of HIV-infected doctors and nurses; consequences for professional and other caregivers, friends and families, and, finally and uniquely, psychoneuroimmunologic aspects of HIV infection.
The book opens with an admirably accurate, necessarily simplified account of the immunology/pathophysiology of HIV infection, as well as classifications. The variability of the clinical picture at any given low level of CD4 cell count and the variability of worsening of "prognostic markers" (like CD4 "helper" T cell counts) is pointed out, but not sufficiently emphasized. This reviewer agrees that diagnosis by count (now an official CDC criterion) can be psychologically damaging. A clear differentiation is made between realistic fear of infection (in contradistinction to denial) that leads to appropriately careful sexual behaviors and persistent anxiety, sexual phobias, somatic preoccupation, and even delusional conviction or factitious simulation of HIV infection. The author mentions "deliberate attempts" to contract HIV but does not adequately explore varied unconscious self-destruction motivations. The discussion of psychological reactions to HIV antibody testing is more relevant than ever, now that approval of home testing kits (with telephonic counseling) is being considered by the FDA. The discussion of the nature and prevalence of psychological/psychiatric problems/disorders in HIV-infected persons, unfortunately but understandably in view of the skew of the literature, is weighted towards but not limited to gay men and does emphasize the importance of longitudinal studies. A short section briefly points out that studies of long-term survivors have found remarkably adaptive attitudes and coping skills. The inconsistent literature on suicide, including a discussion of assisted suicide, is covered. Cultural and subcultural factors are given, relative to their importance, short-shrift. Assessment, diagnosis, and management get "once over lightly". Direct immunosuppressive effects of psychotropic drugs are not mentioned. (Recent Literature suggests that tricyclics, in spite of some negative in vitro evidence, are safe but perhaps less so than SSRIs. Lithium, uniquely, is immunoenhancing in animal experiments but was found to be useless as a treatment for AIDS.) Benzodiazepines are referred to as a "fraught issue." Here, I should like to criticize the author more generically. He covers and summarized the literature well but is most timid about coming to very many editorial or even tentative personal opinions based on that literature. In discussing management of HIV seropositive psychiatric inpatients, Dr. King does not address the issue of intent to engage in or inability to refrain from unsafe sex practices, even with a specific partner (a U.S. "Tarasoff" problem). Parenthetically, I was a bit surprised that even Englishmen improperly make verbs of nouns, viz., writing "to liase" in the context of management.
