Triple Diagnosis: AIDS, Addiction, and a Psychiatric Disorder

To be eligible to reside at PSI, the patients must have AIDS and substance addiction. Frequently, however, there is a third diagnosis of a psychiatric disorder as well. I remember learning in my psychiatry class in school about the co-morbidity of drug dependence and mental illness; people suffering from drug addiction are over 2 times more likely to have an anxiety disorder and over 4 times more likely to have a mood disorder such as depression. Having a disease with such social stigma such as AIDS contributes to a higher incidence of psychiatric disease as well. So needless to say, the psychiatric nurse practitioner and mental health counselors here are kept very busy.

In my short time at PSI this summer, I have seen many different psychiatric symptoms that are likely indicative of an underlying disorder. To name a few:

• Suicidal ideation. When I asked one of the patients how she was doing that day, she replied, "Still breathing, unfortunately." Concerned, I asked, "Do you really mean that?" She told me that she did.
• Grandiose delusions. One patient adamantly believes that HIV does not exist. He insists that it was invented by the Surgeon General to make money off of antiretroviral drugs sold by the pharmaceutical companies.
• Paranoid traits. One patient here always thinks the world is out to get her. She often refuses to reply to the journal questions in my class, asking, "Why are you trying to pick my brain?". More than once, she has referred to herself and other patients as "guinea pigs" that doctors are using to test out antiretroviral medication.
• Antisocial traits. One patient used to belong to a machete-wielding gang in Puerto Rico, and has done hard time in jail for having dismembered body parts in his car. Despite this, he has no remorse.
• Symptoms of Conduct Disorder. I had the privilege of observing the Anger Management group, in which several patients described the extreme satisfaction they get out of physical aggression towards others.

This may be a chicken and the egg type of situation - which came first, the psychiatric illness, the drug addiction, or AIDS? The Lancet had a great review article last month, detailing the intricacies in treating patients with this triple diagnosis. The article (justifiably) calls for more funding and research in this area to be able to successfully treat these patients who so desperately need the help of the medical community.