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Somatic Symptoms: Mental Health Approach and Differential Diagnosis

November 2008

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VII. Appetite and Weight Loss

A. Assessment and Diagnosis

Recommendation:

Clinicians should refer patients with depression that is associated with significant weight loss, anorexia symptoms, and psychomotor retardation for psychiatric evaluation.

Malnutrition and being underweight affect quality of life and place HIV-infected people at risk for increased morbidity and mortality. Depression can be associated with anorexia, weight loss, and psychomotor retardation. These patients should be referred as soon as possible for psychiatric evaluation.

Table 8 provides some medical and mental health etiologies associated with weight loss.


Table 8: Differential Diagnosis for Patients With Appetite and Weight Loss
Medical Etiologies
Dietary restrictions Suboptimal caloric intake can result from medication side effects, gastrointestinal conditions, or poor dental health
Malignancy Patients with cancer, particularly advanced cancer, often present with weight loss and anorexia
Hypogonadism Androgen insufficiency often occurs in HIV-infected men and women and results in weight loss in association with loss of both lean body mass and bone mineral density25,26
Mental Health Etiologies
Depression, mania, and anxiety disorders These disorders can cause either an increase or a decrease in appetite and may be associated with weight change
Substance use Substance use, particularly methamphetamine, cocaine, and heroin use, can be associated with decreased appetite and weight loss
Eating disorders
  • Anorexia nervosa
  • Bulimia nervosa*
* Bulimia nervosa can also be associated with weight gain.


B. Management

Poor appetite and inadequate caloric intake can lead to increased side effects from ARV therapies, which can lead to poor adherence. Additionally, weight redistribution or abnormal redistribution of body fat can occur with ARV treatment. Patients experiencing disfigurement attributable to ARV therapy are at risk for developing depressive symptoms.27

A registered dietician can work with patients to prescribe an acceptable nutritional plan. Nutritional supplements may benefit patients who are unable to consume enough food to meet daily caloric requirements. The use of anabolic steroids or dronabinol may help alleviate wasting in HIV-infected patients. Inpatient parenteral nutritional therapy may be necessary in extreme cases. Weight loss attributable to hypogonadism may be alleviated by hormone replacement therapy.

Refer to the Clinical Guidelines for the Treatment of HIV-Infected Adults: General Nutrition, Weight Loss, and Wasting Syndrome.


VIII. Sexual Dysfunction

A. Assessment and Diagnosis

Recommendations:

Clinicians should assess for sexual dysfunction in HIV-infected patients by inquiring about types, patterns, and frequency of sexual behaviors.

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Clinicians should attempt to distinguish between the potential psychological and biological factors of sexual dysfunction.

Clinicians should refer patients with potentially dangerous sexual behavior to mental health services or a program with appropriate expertise when possible.

Sexual dysfunction is a complex issue for many clinicians treating HIV-infected patients.  Management considerations involve not only treatment of the symptoms and improvement of patients' sexual health but also behavioral counseling to ensure that patients practice safe sex, particularly effective barrier protection, to avoid HIV transmission. Assessment for sexual dysfunction can enable detection of medical, mental health, psychosocial, and substance use disorders associated with sexual dysfunction.

The potential factors for sexual dysfunction can be classified into those that are biological and psychological (see Table 9). However, in the majority of cases, a combination of psychological and biological factors is responsible for sexual dysfunction.

Patients experiencing more complex problems, such as significant difficulties within a relationship, substance use, history of a traumatic sexual experience or abuse, or severe depression and anxiety disorders, may require referral for mental health services. Patients with persistent patterns of compulsive sexual behavior that have an addictive quality may develop a high frequency of risky behaviors and may need specialized treatment for this problem.


Table 9: Biological and Psychological Factors Associated With Sexual Dysfunction
Biological Factors

Metabolic
 
  • Hyperglycemia/diabetes
  • Lipodystrophy

Endocrine
  • Hypogonadism
  • Hyperthyroidism
  • Hypothyroidism
  • Hyperprolactinemia

Neurologic
  • Central nervous system interference, including that induced by antidepressants
  • Spinal cord injury
  • Peripheral neuropathy

Cardiovascular
  • Atherosclerosis
  • Hypertension
  • Dyslipidemia

Infection
  • Pelvic inflammatory disease
  • Balanitis/vulvovaginitis
 Iatrogenic
  • Medication-related
  • Medication interactions
  • Radiotherapy
  • Surgical
Psychological Factors
  • Traumatic sexual experience or abuse
  • Poor sex education
  • Psychosocial barriers to healthful living
  • Substance use
  • Depression
  • Anxiety
  • Reaction to lipodystrophy
  • Relationship problems
  • Loss of partner
  • Performance anxiety
  • Diminished libido
  • Poor communication skills
  • Fear of transmitting HIV
  • Fear of superinfection with treatment-resistant HIV or infection with another STI


B. Management

Recommendation:

Clinicians should establish a treatment plan for sexual dysfunction after determining the patient's specific symptoms and/or any known underlying factors.

The treatment of sexual dysfunction in HIV-infected patients is based on the specific symptoms and/or any known underlying factors.

Lifestyle changes, including quitting smoking, losing excess weight, and increasing physical activity, may help some people overcome sexual dysfunction. Consideration of changing medications for certain medical conditions may also be appropriate.

Hypogonadism is a common cause of not only sexual dysfunction but also low mood, fatigue, and weight loss in HIV-infected men and women. Replacement therapy with testosterone may be beneficial in men. Testosterone has been used in women, but its safety and efficacy have not been established. Low estrogen levels in women can result in too little lubrication, vaginal epithelial atrophy, and dyspareunia. After consideration of the potential risks and benefits, limited estrogen replacement therapy, particularly in the form of estrogen vaginal gel, may provide relief from these symptoms. Commercial, water-based vaginal lubricants also may ameliorate the symptoms of vaginal atrophy and painful sex.

In men, premature ejaculation can be treated with SSRIs and/or sex therapy. However, SSRIs and many other psychotropic medications have side effects that can interfere with sexual function.

For erectile dysfunction (ED), the phosphodiesterase inhibitors sildenafil citrate (Viagra), vardenafil hydrochloride (Levitra), and tadalafil (Cialis) may be considered. However, their effects on cardiovascular function require careful assessment of patients' cardiovascular risk. Contraindications for these medications include concomitant treatment with nitrate-based drugs, hypotension, cardiovascular risk factors, and severe hepatic and renal impairment. Special consideration is required for patients receiving treatment with α-blockers because of the risk of a sudden decrease in blood pressure when the drugs are taken within a short time of one another (within approximately 4 hours). Dosing considerations are also necessary when ED medications are used with ARV therapy.

Refer to the Clinical Guidelines for the Treatment of HIV-Infected Adults: HIV Drug-Drug Interactions: Erectile Dysfunction Drugs.

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This article was provided by New York State Department of Health AIDS Institute.
 
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