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Reclaiming Emotional Wellness

The Challenges of HIV and Mental Health

November/December 2011

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Anxiety Disorders

Anxiety disorders are common among those living with HIV. One recent study found that as many as 45% of HIV-positive individuals also had an anxiety disorder.10 Surprisingly, these rates were highest among those on antiretroviral medications with an undetectable viral load. Anxiety disorders significantly impact an individual's quality of life and have an adverse effect on adherence to medications and other treatment interventions. There is also evidence that chronic anxiety affects hormonal balance in such a way that immune function is impeded.11

Symptoms of anxiety range from those that are barely noticeable to paralyzing panic attacks, making them difficult at times to diagnose. Many symptoms are physiological, such as a racing pulse, chest pain, sweating, and hyperventilation. Brian, mentioned above, experienced disabling symptoms of panic based on his fear of having become infected by his partner Paul. Anxiety disorders frequently occur with other mood disorders. For example, as many as half of individuals who experience panic disorder also experience MDD.12 Women experience anxiety disorders, particularly panic disorder, more frequently than men.13

Post-traumatic stress disorder (PTSD) can result from witnessing or experiencing an event beyond what would be considered normal and which involves the threat of death or actual injury. As noted earlier, a history of abuse can increase the risk of PTSD among persons living with HIV. Symptoms, such as those described for Angela, include frightening physiological reactions, nightmares, and other symptoms of emotional shock. PTSD can result in social withdrawal and a sense of a foreshortened future.

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Treatment for anxiety disorders often includes pharmacological interventions. Specific SSRIs (noted above for treatment of depression) are effective for certain anxiety disorders, including obsessive-compulsive disorder (OCD). Other medications are approved to treat anxiety, including buspirone and some beta blockers. Benzodiazepines can be effective at resolving acute symptoms of anxiety but, because of their addictive potential, should only be used in the short-term and with great caution in anyone with a history of substance abuse. Benzodiazepine withdrawal is dangerous and should always occur under the direction of a physician.

Psychotherapy is also an effective means of treating anxiety disorders. Cognitive behavioral therapy can greatly reduce symptoms of anxiety by focusing on thought patterns and the "here and now." Therapy can also teach various stress management techniques that significantly improve one's ability to engage in social and medical activities. Specialized treatment techniques such as hypnotherapy and EMDR (eye movement desensitization and reprocessing), among others, are effective for treating PTSD.

In addition to medication and therapy, anyone experiencing symptoms of anxiety should refrain from ingesting caffeine. Symptoms can also be controlled through increased exercise and relaxation procedures such as deep breathing and meditation.


Substance Abuse

The use of recreational drugs along with the abuse of prescription medication, particularly benzodiazepines and opiates, is intimately bound to HIV and mental health. Addiction increases both the risk of acquiring HIV and greatly complicates the medical and psychological management of living with the virus. The desire to numb feelings or escape into fantasy, despite potential life-threatening complications, is seductive for many with HIV. The grief of cumulative losses, shame, fear, and other overwhelming feelings can easily propel someone to the short-term relief of a mood-altering substance.

While a comprehensive discussion of substance abuse is beyond the scope of this article, it is important to note how HIV, mental health, and substance abuse converge into syndemics, or simultaneous epidemics, each impacting the other. One striking example is the methamphetamine epidemic among gay men. Meth is an amphetamine that works on the pleasure center of the brain, releasing a torrent of dopamine that quickly washes away any feelings of inhibition and even depression. It also triggers intense sexual thoughts that can result in high-risk sexual marathons.

While meth is a risk factor for becoming HIV-positive, it creates havoc among those who have already sero-converted. I work with many gay men in their 40s and 50s who have lived with the virus for years. Many have begun to feel less energetic, less attractive, less sexual, and socially isolated. Meth washes away these concerns, creating an artificial sense of confidence and empowerment. A significant number of meth users soon become drawn into a vortex of increased drug use and severe social, medical, and sometimes legal consequences. Many stop taking their antiretroviral medications, which can create drug resistance. The depletion of dopamine can result in severe depression and feelings of hopelessness which can persist well into recovery because the brain requires months to "rewire" neural pathways damaged by the drug.

There are many resources available to anyone seeking assistance for substance abuse. Medications can reduce cravings for certain types of drugs. Support groups, whether twelve-step or alternative, such as SMART Recovery, have saved thousands of lives. Counseling can assist with underlying issues as well as the development of relapse prevention plans. Recognizing substance abuse and taking steps to reduce its harm can have a tremendous impact on HIV-related mental health concerns.


Building Emotional Resilience

HIV presents formidable barriers to achieving and maintaining emotional well-being. Despite these challenges, there are steps that anyone living with HIV can take to promote their own mental health and quality of life. Here are a few that can build emotional resilience:


Collaborate With Your Healthcare Providers

Carefully monitor your emotional state and share any concerns with your physician or other providers. Certain disorders require pharmacological intervention. If your depressed, manic, or anxious moods seem beyond your control, you might benefit from medication that could give you a stable foundation on which to implement the other suggestions in this section.


Identify and Express Feelings

Living with HIV produces a number of negative emotions which must be identified and released. Whether at the initial diagnosis, when making the decision to begin meds, or during a medical setback, an emotional process ensues which can include a swirl of anger, denial, and sadness. Because holding on to these feelings aggravates both physical and mental conditions, it is important to find ways to release them through verbal expression, physical exercise, creative endeavors, or any other means possible.


Maintain Social Support

HIV, in many cases, creates increased isolation and loneliness. Physical mobility, feeling ill, shame, and depression can all contribute to a withdrawal from society. It is critical to fight the urge to isolate and to re-establish connections with others. Social contact promotes healing at a number of levels and benefits not only the individual but everyone they come in contact with.


Live Consciously

Each of us needs emotional nourishment to heal. Many people derive strength from their spiritual life. Others find that nature, or work in the garden, or playing with their pet can ground them and re-establish emotional balance. Maintaining an awareness of our inner thoughts and feelings assists us in overcoming stigma, shame, and other negative emotions, and in expanding our connection with others and our role in a larger healing community.


Practice Daily Self Care

Daily healthy routines are not only beneficial in and of themselves, but they subtly affirm our inner sense of value and worth. A healthy diet, adequate sleep, minimal use of mood altering substances, and physical exercise all contribute enormously to mental health. Remaining focused on the present and not letting our thoughts drift too frequently into the past or the future can greatly reduce stress. If negative emotions take hold, a simple act, such as creating a list of things for which we are grateful, can often bring us back into balance. Any actions that reinforce personal empowerment are beneficial for our health and our emotions.

Living with HIV creates challenges to mental health that cannot be underestimated, yet the power to create positive feelings, healthy relationships, and an inner sense of peace lies within each of us. When we maintain our emotional balance, HIV can remain just one piece of the rich emotional mosaic of our lives.

David Fawcett is a psychotherapist and clinical hypnotherapist in private practice in Fort Lauderdale, Florida. He is active in the gay men's health movement, writes regularly for TheBody.com, and is a national trainer for the National Association of Social Workers' "HIV Spectrum Project."


References

  1. Gannon P, Khan MZ, Kolson DL. (2011). Current understanding of HIV-associated neurocognitive disorders pathogenesis. Current Opinion in Neurology 2011 Jun;24(3):275-83.
  2. Cohen RA, Harezlak J et.al. (2010) Effects of nadir CD4 count and duration of human immunodeficiency virus infection on brain volumes in the highly active antiretroviral therapy era. Journal of Neurology 2010 Feb;16(1):25-32.
  3. AETC National Resource Center. (2011). HRSA Clinical Guide: HIV-Associated Dementia and Other Neurocognitive Disorders. Guide for HIV/AIDS Clinical Care, HRSA HIV/AIDS Bureau. 2011 Jan.
  4. Berger-Greenstein JA, Cuevas CA, Brady SM et.al. (2007) Major depression in patients with HIV/AIDS and substance abuse. AIDS Patient Care and STDS. 2007 Dec;21(12):942-55.
  5. Kalichman SC, Heckman T, Kochman A, et.al. (2000) Depression and thoughts of suicide among middle-aged and older persons living with HIV-AIDS. Psychiatric Services 2000; 51:903-907.
  6. Simoni JM, Ng MT. (2000) Trauma, coping, and depression among women with HIV/AIDS in New York City. AIDS Care 2000; 12:567-580.
  7. Bing EG, Burnam MA, Longshore D, et.al. (2001) Psychiatric disorders and drug use among human immunodeficiency virus-infected adults in the United States. Archives of General Psychiatry 2001; 58:721-728.
  8. Badiee J, Moore DJ, Atkinson JH, et.al. (2011) Lifetime suicidal ideation and attempt are common among HIV+ individuals. Journal of Affective Disorders. 2011 Jul 22. [Epub ahead of print].
  9. Murphy, G., Simons, A., Wetzel, R., & Lustman, P. (1984). Cognitive therapy and pharmacotherapy, singly and together in the treatment of depression. Archives of General Psychiatry, 1984; 41, 33-41.
  10. Kemppainen JK, Wantland D, Voss J, et.al. (2011J Self-Care Behaviors and Activities for Managing HIV-Related Anxiety. Association of Nurses in AIDS Care. 2011 Aug 10. [Epub ahead of print].
  11. Antoni MH. (2003) Stress management effects on psychological, endocrinological, and immune functioning in men with HIV infection: empirical support for a psychoneuroimmunological model. Stress 2003; 6:173-188.
  12. Sakami S, Maeda M, Maruoka T, et.al. (2004) Positive coping up- and down-regulates in vitro cytokine productions from T cells dependent on stress levels. Psychotherapy and Psychosomatics 2004; 73:243-251.
  13. Andrade L, Eaton WW, Chilcoat HD. (1996). Lifetime co-morbidity of panic attacks and major depression in a population-based study: age of onset. Psychological Medicine 1996; 26:991-996.
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This article was provided by Positively Aware. It is a part of the publication Positively Aware. Visit Positively Aware's website to find out more about the publication.
 
See Also
Guide to Conquering the Fear, Shame and Anxiety of HIV
Trauma: Frozen Moments, Frozen Lives
More on Coping With Mental Health Issues

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