The worried well
Patients known as the “worried well” present with multiple physical complaints which they interpret as sure evidence of their HIV infection. Typically, fears of infection reach obsessive proportions and frank obsessive and hypochondriacal states are often seen.
This group shows a variety of characteristic features, and they are rarely reassured for more than a brief period after clinical or laboratory confirmation of the absence of HIV infection. A further referral for behavioural psychotherapy or psychiatric intervention may be indicated, rather than frequent repetition of HIV testing.Box 13.7 Advantages of counselling patient with their partner
• Adjustments to sexual behaviour and other lifestyle issues can be discussed and explained clearly to both.
• If the patient's partner is HIV negative (i.e. a serodiscordant couple) particular care and attention must be paid to emotional and sexual consequences in the relationship.
• Misconceptions about HIV transmission can be addressed and information on safer sex given.
• The partner's and the patient's psychological responses to the diagnoses or result, such as anxiety or depression, can be explained and placed in a manageable perspective.
• There may be particular issues for couples who have children or who are hoping to have children or where the woman is pregnant.
Box 13.8 Causes of uncertainty
• The cause of illness:
Progression of disease
Management of dying Prognosis
Reactions of others (loved ones, employers, social networks)
• Effects of treatment
• Long-term impact of antiretroviral therapy
• Impact of disclosure and how this will be managed
Box 13.9 Characteristics of the worried well
• Repeated negative HIV tests
• Low-risk sexual history, including covert and guilt-inducing sexual activity
• Poor post-adolescence sexual adjustment
• Social isolation
• Dependence in close relationships (if any)
• Multiple misinterpreted somatic features usually associated with undiagnosed viral or postviral states (not HIV) or anxiety or depression
• Psychiatric history and repeated consultation with general practitioners or physicians
• High levels of anxiety, depression and obsessional disturbance
• Increased potential for suicidal gestures