Abstract
Treatment adherence by patients with HIV ensures they gain the full benefit of antiretroviral medications and extend their lives. One problem which may contribute to poor adherence is deficits in metacognition or the capacity to make sense of mental states. In particular, persons who struggle to notice and think about their thoughts and feelings may be less able to direct their own recovery by taking advantage of effective treatments. This raises the possibility that treatments which lead to improved metacognitive function may enhance treatment adherence. We describe the case of a man in an advanced stage of AIDS with Kaposi’s sarcoma. The patient was treated with Metacognitive Interpersonal Therapy combined with psychoeducation about pharmacological treatment for HIV. Primary medical outcomes were suppression of viral load, increase of CD4 count and control of AIDS related conditions such as Kaposi’s sarcoma. The primary psychological outcome was reduction of personality disorders criteria. The patient was able to understand what led him to discontinue medication and then later regain full adherence. He achieved suppression of viral load and restore of CD4 count. As regard severity of personality disorder, he achieved reliable change. Interventions such as Metacognitive Interpersonal Therapy may assist patients with HIV to gain the metacognitive capacities to make sense of their medical and psychological challenges and adhere to antiretroviral therapies leading to enhanced levels of health. Future studies are needed to explore these findings in larger controlled studies.
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References
Abbass, A. A. (2003). The cost-effectiveness of short-term dynamic psychotherapy. Expert Review of Pharmacoeconomics & Outcomes Research, 3, 535–539.
Abel, E., & Painter, L. (2003). Factors that influence adherence HIV medications: Perceptions of women and health care providers. The Journal of the Association of Nurses in AIDS Care, 14(4), 61–69.
Altice, F. L., & Friedland, G. H. (1998). The era of adherence to HIV Therapy. Annals of Internal Medicine, 129, 503–505.
Bagby, R. M., Parker, J. D. A., & Taylor, G. J. (1994). The twenty item Toronto alexithymia scale I. Item selection and cross validation of the factor structure Journal of Psychosomatic Research, 38, 23–32.
Baldwin, M. W. (1992). Relational schemas and the processing of social information. Psychological Bulletin, 112, 461–484.
Bezabhe, W. M., Chalmers, L., Bereznicki, L. R., Peterson, G. M. (2016). Adherence to antiretroviral therapy and virologic failure: A meta-analysis. Medicine, 95(15), e3361. doi:10.1097/MD.0000000000003361.
Carcione, A., Semerari, A., Nicolò, G., Pedone, R., Popolo, R., Conti, L., Fiore, D., Procacci, M., & Dimaggio, G. (2011). Metacognitive mastery dysfunctions in personality disorder psychotherapy. Psychiatry Research, 190, 60–71.
Chesney, M. A. (1999) The challenge of adherence. Beta. 12, 10–13. [PubMed].
Chesney, M. A. (2000). Factors affecting adherence to antiretroviral therapy. Clinical Infectious Disease, 30(2), S171–S176.
Dimaggio, G., Semerari, A., Carcione, A., Nicolò, G., & Procacci, M. (2007). Psychotherapy of personality disorders: Metacognition, states of mind and interpersonal cycles. London: Routledge.
Dimaggio, G., Carcione, A., Nicolò, G., Lysaker, P. H., d’Angerio, S., Conti, M. L., Fiore, D., Pedone, R., Procacci, M., Popolo, R., & Semerari, A. (2013). Differences between axes depend on where you set the bar. Associations among symptoms, interpersonal relationship and alexithymia with number of personality disorder criteria. Journal of Personality Disorders, 27, 371–382. doi:10.1521/pedi_2012_26_043.
Dimaggio, G., Valeri, S., Ottavi, P., Popolo, R., Salvatore, G., & Montano, A. (2014). Adopting metacognitive interpersonal therapy to treat narcissistic personality disorder with severe somatization. Journal of Contemporary Psychotherapy, 44, 85–95. doi:10.1007/s10879-013-9254-8.
Dimaggio, G., & Lysaker, P. H. (2015). Metacognition and mentalizing in the psychotherapy of patients with psychosis and personality disorders. Journal of Clinical Psychology: In-Session, 71, 117–124. doi:10.1002/jclp.22147.
Dimaggio, G., Montano, A., Popolo, R., & Salvatore, G. (2015a). Metacognitive interpersonal therapy for personality disorders: A treatment manual. London: Routledge.
Dimaggio, G., D’Urzo, M., Pasinetti, M., Salvatore, G., Lysaker, P. H., Catania, D., & Popolo, R. (2015b). Metacognitive interpersonal therapy for avoidant personality disorders and substance abuse. Journal of Clinical Psychology: In-Session, 71, 157–166. doi:10.1002/jclp.22151.
Dimaggio, G., Salvatore, G., Lysaker, P. H., Ottavi, P., & Popolo, R. (2015c). Behavioral activation revised as a common mechanism of change for personality disorders psychotherapy. Journal of Psychotherapy Integration, 25, 30–38. doi:10.1037/a0038769.
Dimaggio, G., Conti, C., Lysaker, P. H., Popolo, R., Salvatore, G., & Sofia. S. A. (2016). Reauthoring one’s own life in the face of being HIV+. Promoting healthier narratives with Metacognitive Interpersonal Therapy. Journal of Constructivist Psychology, 1–16
First, M. B., Gibbon, M., Spitzer, R. L, Williams, J. B. W., & Benjamin, L. S. (1997). Structured clinical interview for DSM-IV axis II personality disorders, (SCID-II). Washington, D.C.: American Psychiatric Press, Inc.
Grierson, J., Bartos, M., De Visser, R., & McDonald, K. (2000). HIV futures II: the health and well being of people with HIV/AIDS in Australia. Monograph Series Number 17. The Australian Res. Centre in Sex, Health, and Society. Melbourne: La Trobe University.
Holzemer, W. L., Corless, I. B., Nokes, K. M., Turner, J. G., Brown, M. A., Powell-Cope, G. M., Inouye, J., Henry, S. B., Nicholas, P. K., & Portillo, C. J. (1999). Predictors of self-reported adherence in persons living with HIV disease. AIDS Patient Care and STDs, 13(3), 185–197.
Jacobson, N. S., & Truax, P. (1991). Clinical significance: a statistical approach to defining meaningful change in psychotherapy-research. Journal of Consulting and Clinical Psychology, 59, 12–19.
Kleeberger, C. A., Buechner, J., Palella, F., Detels, R., Riddler, S., Godfrey, R., & Jacobson, L. P. (2004). Changes in adherene to highly active antiretroviral therapy medications in the multicenter AIDS cohort study. AIDS, 18(4), 683–688.
Langebeek, N., Gisolf, E. H., Reiss, P., Vervoort, S. C., Hafsteinsdóttir, T. B., Richter, C., Sprangers MAG, & Nieuwkerk, P. T. (2014). BMC Medicine, 12, 142. http://www.biomedcentral.com/1741-7015/12/142.
Luborsky, L., & Crits-Christoph, P. (1998). Understanding transference: The core conflictual relationship theme method (2nd edn.). New York, NY: Basic Book.
Lysaker, P. H., & Dimaggio, G. (2014). Metacognitive capacities for reflection in schizophrenia: Implications for developing treatments. Schizophrenia Bulletin, 40, 487–491. doi:10.1093/schbul/sbu038.
Lysaker, P. H., Olesek, K., Buck, K., Leonhardt, B., Vohs, J., Dimaggio, G., Popolo, R., & Outcalt, J. (2014). Metacognitive mastery moderates the relationship of alexithymia with cluster C personality disorder traits in adults with substance use disorders. Addictive Behaviors, 39, 558–561. 10.1016/j.addbeh.2013.11.007.
Lysaker, P. H., Ringer, J. M., Buck, K. D., Grant, M., Olesek, K., Leudtke, B. L., Dimaggio, G., (2012). Metacognitive and social cognition deficits in patients with significant psychiatric and medical adversity a comparison between participants with schizophrenia and a sample of participants who are HIV-positive. The Journal of Nervous and Mental Disease, 200, 130–134.
McIntosh, R. C., Ironson, G., Antoni, M., Fletcher, M. A., & Schneiderman, N. (2016). Alexithymia, assertiveness and psychosocial functioning in HIV: Implications for medication adherence and disease severity. AIDS and Behavior, 20(2), 325–338. doi:10.1007/s10461-015-1126-7.
Moran, G., Fonagy, P., Kurtz, A., Bolton, A., & Brook, C. (1991). A controlled study of the psychoanalytic treatment of brittle diabetes. Journal of the American Academy of Child & Adolescent Psychiatry, 30, 926–935.
Outcalt, J., Dimaggio, G., Popolo, R., Olesek, K. L., Buck, K., & Lysaker, P. H. (2016). Metacognition moderates the relationship of disturbances in attachment with severity of borderline personality disorder among persons in treatment for substance use disorders. Comprehensive Psychiatry, 64, 22–28.
Pence, B. W., Miller, W. C., Gaynes, B. N., & Eron, J. J. Jr. (2007). Psychiatric illness and virologic response in patients initiating highly active antiretroviral therapy. Journal of Acquired Immune Deficiency Syndromes, 44(2), 159–166.
Pratt R, Robinson N, Loveday HP, Pellowe CM, Franks PJ. (1998). Improvement in sexual drive and a falling viral load are associated with adherence to HAART therapy. Geneva: 12th World AIDS Conference.
Safran, J. D., & Muran, J. C. (2000). Negotiating the therapeutic alliance. A relational treatment guide. New York, NY: Guilford.
Semerari, A., Carcione, A., Dimaggio, G., Falcone, M., Nicolò, G., Procacci, M., & Alleva, G. (2003). How to evaluate metacognitive functioning in psychotherapy? The metacognition assessment scale and its applications. Clinical Psychology and Psychotherapy, 10, 238–261.
Semerari, A., Carcione, A., Dimaggio, G., Nicolò, G., & Procacci, M. (2007). Understanding minds, different functions and different disorders? The contribution of psychotherapeutic research. Psychotherapy Research, 17, 106–119.
Spielberger, C. D., Gorsuch, R. L., Lushene, R., Vagg, P. R., & Jacobs, G. A. (1983). Manual for the State-Trait Anxiety Inventory. Palo Alto, CA: Consulting Psychologists Press.
Starace, F., Ammassari, A., Trotta, M. P., Murri, R., De Longis, P., Izzo, C., et al. (2002). Depression is a risk factor for suboptimal adherence to highly active antiretroviral therapy. Journal of Acquired Immune Deficiency Syndromes, 31(3), 136–139.
Tseng, A. (1998). Compliance issues in the treatment of HIV infection. American Journal of Health-System Pharmacy, 55(17), 1817–1824.
Verheul, R., Bartak, A., & Widiger, T. (2007). Prevalence and construct validity of personality disorder not otherwise specified. Journal of Personality Disorders, 21, 359–370.
Westerfelt, A. (2004). A qualitative investigation of adherence issues for men who are HIV positive. Social Work, 49(2), 609–615.
Wilberg, T., Hummelen, B., Pedersen, G., & Karterud, S. (2008). A study of patients with personality disorder not otherwise specified. Comprehensive Psychiatry, 49, 460–468.
Williams, A., & Friedland, G. (1997). Adherence, compliance, and HAART. AIDS Clinical Care, 9(7), 51–53.
Author Contributions
All authors have made substantial contributions to conception and design of the study. All authors have been involved in drafting the manuscript and revising it critically for important intellectual content. All authors read and approved the final manuscript. S.S. has carried out patient psychotherapy. G.D. has carried out the supervision of the psychotherapy.
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Written informed consent was obtained from the patient for publication of this case report. A copy of the written consent is available for review by the Editor of this journal.
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The datasets analyzed during the current study are not publicly available. The datasets deposited in the infectious diseases department of the University of Catania, but are available from the corresponding author (S.S.) on reasonable request.
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Sofia, S.A., Lysaker, P.H. & Dimaggio, G. Metacognitive Interpersonal Therapy Improves Adherence to Antiretroviral Therapies in a Man with a Severe Personality Disorder: A Case Report. J Contemp Psychother 47, 223–232 (2017). https://doi.org/10.1007/s10879-017-9363-x
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DOI: https://doi.org/10.1007/s10879-017-9363-x