HIV-1-Associated Cognitive-Motor Disorders: A Research-Based Approach to Diagnosis and Treatment.

The diagnosis of human immunodeficiency virus type 1 (HIV-1)-associated cognitive-motor disorder--either minor cognitive-motor disorder (MCMD) or HIV-1-associated dementia (HAD)--is fraught with potential pitfalls for the clinician. Before making such a diagnosis, clinicians should exclude other etiologies by using neuroimaging, lumbar puncture, and serum chemistries to screen for opportunistic and non-opportunistic infections of the brain and meninges. Clinicians should also consider psychoneurotoxicity (caused from the use of psychoactive substances and prescribed medications) and psychopathology, such as mood, anxiety, and other disorders. In addition, a thorough medical history and physical examination, including a complete neurologic and neuropsychiatric mental status examination, are necessary for an accurate diagnosis. There is also a need for standardized neuropsychological and functional status tests, since the diagnostic criteria for these disorders are partly based on these criteria. Treatment targets should include subclinical cognitive-motor impairment and neuroprotection, as well as MCMD and HAD. Currently, zidovudine remains the best proven treatment for these disorders, but other nucleoside reverse transcriptase inhibitors, as well as nonnucleoside reverse transcriptase inhibitors and protease inhibitors, show promise, and selected agents from these classes are being tested in clinical trials. Other areas that should be investigated are the modulation of inflammatory mediators (such as tumor necrosis factor alpha), neurotransmitter manipulation (especially of dopamine), and nutritional interventions.

Current issues in the diagnosis and management of malingering.

Malingering is a diagnosis that is frequently avoided by physicians. When there is a claim of symptoms or diseases that either are exaggerated or do not exist, the diagnosis of malingering should be entertained. Malingering is associated with a conscious intent to deceive in order to obtain a known gain. Psychoanalytical, criteria-based (DSM-IV) and 'adaptational' models have been advanced to explain malingering. The differential diagnosis of malingering includes factitious disorder, the somatoform disorders, the dissociative disorders, and specific medical conditions without somatoform disorder. Upon consideration of the differential diagnosis, confirmation of the suspicion of malingering is still required in order to make the diagnosis. Confirmation can be achieved by observation or by inferential methods. Observation can be employed with controlled environment observation or with covert, 'real-world' surveillance; inference may involve primary and/or secondary source information. It may be concluded that a greater attempt should be made to identify this diagnosis, as the cost of malingering to society is considerable.

The role of precise conceptualization in the treatment of a complicated HIV-1-infected neuropsychiatric patient.

Patients infected with human immunodeficiency virus, type 1, may present with neuropsychiatric manifestations across all stages of disease. Frequently, these patients may present with more than one neuropsychiatric disorder concomitantly. The case presented highlights the utility of detailed clinical observation, careful use of medical terminology, and a neuropsychiatric organizing paradigm in the diagnosis and treatment of a patient presenting over time with delirium, aphasia, mania, and a complex partial seizure disorder.