The video below is the section for Neurocognitive Disorder Due to HIV Infection from Part 2 of TSM’s lecture series on DSM-5 and the EPPP, followed by a transcript. This lecture series aims to equip those preparing for the EPPP with everything one needs to know about the impact DSM-5 will be having on the EPPP. To watch all of Part 2, click here. To watch Part 1, click here. To register for our webinar series to watch future lectures and discuss your questions with a content expert, click here.
Transcript of DSM-5 EPPP Lecture Video: Neurocognitive Disorder Due to HIV Infection
NARRATIVE DEFINITION: According to the Centers for Disease Control and Prevention, approximately 1.2 million people in the United States are infected with Human Immunodeficiency Virus (HIV). HIV is transmitted via blood, semen, vaginal secretions, and breast milk. Risk factors that increase one’s likelihood of contracting HIV include engaging in unprotected sex with multiple partners; engaging in unprotected sex with HIV-positive partners; sharing needles during intravenous drug use; having other sexually transmitted diseases (e.g., syphilis, herpes, bacterial vaginosis) and having fewer copies of the CCL3L1 gene, which is thought to help fight off the HIV infection.
The progression of HIV is typically divided into three stages. The first stage begins after the immediate infection and lasts for two to six weeks. Although an individual may be asymptomatic during the first stage, the more common presentation is to have a flu-like illness, with symptoms such as fever, headaches, sore throat, rashes, and swollen lymph glands.
During the second stage, which generally lasts for eight years or longer, the immune system is still fighting the virus. For this reason, few symptoms may be noticeable in the second stage, although swollen lymph nodes may be present. As the virus multiplies and destroys more immune cells, mild infections or chronic symptoms such as diarrhea, weight loss, cough, or shortness of breath may appear.
The third stage typically occurs 10 or more years after the initial infection. At this point, opportunistic infections (e.g., pneumocystis pneumonia, tuberculosis) develop, and the infection may meet official criteria for a diagnosis of Acquired Immune Deficiency Syndrome, or AIDS.
Major or Mild Neurocognitive Disorder Due to HIV Infection, according to the DSM-5, can only be diagnosed when criteria for either Major or Mild Neurocognitive Disorder (NCD) have been met and the individual has been diagnosed with HIV infection. Approximately 25% of individuals diagnosed with HIV will also develop Mild NCD, while less than 5% will meet criteria for Major NCD.
Major Neurocognitive Disorder is diagnosed when there is significant cognitive decline from a previous level of performance, as noted by a knowledgeable informant or by documentation from standardized neuropsychological testing. This decline is substantial enough to interfer with complex activities of daily living, such as paying bills, holding a job, managing medications, etc.
Mild Neurocognitive Disorder contrasts with Major Neurocognitive Disorder by level of severity. Knowledgeable informants note a mild decline, or neuropsychological testing finds some modest impairment from previous levels. Mild NCD does not necessarily interfer with activities of daily living, but more effort is put forth to accomplish these activities.
Neither Mild nor Moderate NCD is better explained by delirium or some other mental disorder.
The earliest symptoms of NCD Due to HIV Infection are impaired concentration and forgetfulness. As the dementia progresses, symptoms such as cognitive slowness, impaired problem-solving abilities, ataxia, hypertonia, tremors, weakness, lack of balance and hyperactive physiological reflexes may occur. Apathy, social withdrawal, and depression are also common. Individuals with HIV, who are older adults, have somatic symptoms of depression, and have a lower IQ have been found to be at risk for a more rapid progression of the dementia.
In the late stages of NCD Due to HIV Infection, more severe symptoms often appear, including seizures, partial paralysis, incontinence, delusions, and hallucinations. Death usually follows one to six months after the onset of these symptoms.
The progression of Major or Minor Neurocognitive Disorders Due to HIV Disease is categorized into stages based on the level of impairment. At Stage 0.5 (Subclinical), symptoms result in minimal impairment without deficits in activities of daily living. At Stage 1 (Mild), there is unequivocal evidence of functional, intellectual, or motor impairments, but patients are able to perform most activities of daily living and are fully ambulatory. At Stage 2 (Moderate), patients are unable to work or perform demanding activities of daily living, but are able to perform basic self-care activities; they require some assistance in walking. At Stage 3 (Severe), patients demonstrate significant intellectual impairments and cannot walk unassisted. At Stage 4 (End Stage), patients are nearly vegetative.
Although there is no cure for Major or Minor Neurocognitive Disorders Due to HIV Disease, highly active antiretroviral therapy (HAART) may prevent or delay its onset in HIV-positive individuals who do not yet have cognitive impairments. HAART may also slow the progression of the dementia in individuals already diagnosed with the disorder.
Like Major or Minor Neurocognitive Disorders Due to Parkinson’s and Huntington’s Diseases, Major or Minor Neurocognitive Disorders Due to HIV Disease is a subcortical dementia. This kind of dementia commonly involves diffuse, multifocal destruction of the brain’s white matter and subcortical regions. Subcortical dementia manifests differently than does cortical dementia such as Alzheimer’s Disease. Compared to individuals with Major or Minor Neurocognitive Disorders due to Alzheimer’s Disease, individuals with Major or Minor Neurocognitive Disorders Due to HIV Disease are more likely to experience motor slowness and severe depression, but less likely to experience aphasia.
The DSM-5 uses the diagnosis Major or Minor Neurocognitive Disorders with specifiers to note the cause. The difference between major or minor would come from whether or not the cognitive decline from previous level of performance was significant (major) or modest (minor) and whether the cognitive deficits interfere with their independence in every day activities (major) or they do not interfere with everyday activities (minor). Dementia Due to HIV would be categorized as a Major or Minor Neurocognitive Disorder due to HIV infection.
The diagnosis may also specify Without behavioral disturbances or With behavioral disturbances and include a severity specifier of Mild or Moderate in reference to ability to manage daily activities.
FLASHCARD:
- Dementia Due to HIV Disease
- Human Immunodeficiency Virus (HIV) is a progressive viral disease, with three stages. The first stage begins after the immediate infection and lasts for two to six weeks and the second stage, which generally lasts for eight years or longer, the immune system is still fighting the virus.
- During the third stage typically occurs 10 or more years after the initial infection. At this point, opportunistic infections develop, and the infection may meet official criteria for a diagnosis of Acquired Immune Deficiency Syndrome, or AIDS
- Approximately 25% of individuals diagnosed with HIV will also develop Mild NCD, while less than 5% will meet criteria for Major NCD.
- Major or Minor Neurocognitive Disorders Due to HIV Disease is related to cognitive and behavioral effects of HIV, related to effects of the virus on the brain
- Usually occurs in the second and third stage of the infection
- It is a subcortical dementia, involving diffuse, multifocal destruction of the brain’s white matter and subcortical regions
- Progresses from impaired concentration and forgetfulness to more severe neurological signs
- Highly active antiretroviral therapy (HAART) may prevent or delay its onset in HIV-positive individuals who do not yet have cognitive impairments. HAART may also slow the progression of the dementia in individuals already diagnosed with the disorder
- Stages of progression of Major or Minor Neurocognitive Disorders involve:a. Subclinical (symptoms result in minimal impairment without deficits in activities of daily living)b. Mild (there is unequivocal evidence of functional, intellectual, or motor impairments, but patients are able to perform most activities of daily living and are fully ambulatoryc. Moderate (patients are unable to work or perform demanding activities of daily living, but are able to perform basic self-care activities; they require some assistance in walking
d. Severe (patients demonstrate significant intellectual impairments and cannot walk unassisted
e. End Stage (patients are nearly vegetative)
QUESTION:
513: Compared to an individual with a Major or Minor Neurocognitive Disorder due to Alzheimer’s Disease, someone with a Major or Minor Neurocognitive Disorder Due to HIV Disease is less likely to present with symptoms of:
ANSWERS:
A. aphasia.
B. depression.
C. hypertonia.
D. motor slowness.
RATIONALE: A is correct, as the narrative indicates that Major or Minor Neurocognitive Disorders Due to HIV Disease is less likely to present with aphasia than are other forms of Major or Minor Neurocognitive Disorders. The other responses are distractors.