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Survival Strategies

Learning to Take It Easy

A Simple Program of Stress-Reduction That Can Improve Your Outlook -- and Your CC4 Count

April 1998

Most of us know that stress consumes CD4 cells. The connection between high-level stress and lowered immune protection has been recognized since the beginning of the AIDS epidemic. Back when HIV disease was known as "gay-related immune deficiency" or even as "gay cancer," care providers were already counseling patients to avoid stress and strong sunlight, because both were believed to nibble away at those patients' already compromised immune systems.

As it turns out, this was very good advice, even if it was based, back then, on less persuasive scientific evidence than we have today. It remains good advice -- and we now have scores of studies which show that high-level stress has a negative impact on immune function. More importantly, we now have studies which show that stress-reduction has a positive impact on immune function.

Over the past decade, teams of researchers have established that the body's immune system is directly influenced by anger, anxiety, grief, fear, depression, and other psychological processes. Until these researchers published their findings, the immune system was thought to be a completely independent body system, one responsive only to the battle between germs and immune cells. The common belief was that the immune system regulates itself, that it is not influenced by other physiological systems, and that immunity is not influenced by psychological events. We now know that this picture is both incomplete and inaccurate.

What recent research has revealed is that the immune system is directly linked to the psyche by a complex network of nerves, hormones, and neuropeptides. This network of physiological pathways allows thoughts and emotions to have a direct impact on immune function and, consequently, on physical health.

We now know, for example, that profound psychological stress can suppress immune function and thereby accelerate disease progression in HIV-positive individuals. This is particularly true of what psychologists call "sustained survival stress" -- which is defined by its duration (longer than four to six months) and by its nature (related to safety, security, or survival issues). But how does a psychological state like sustained survival stress affect a biological process like immune function?

The belief that one's safety, security, or survival is threatened can trigger the so-called fight-or-flight response. The mind focuses on the survival problem, the emotions become agitated, and a state of heightened physical and psychological arousal is maintained until some action or event diminishes the threat.

When the human body responds to stress, heart rate accelerates, blood flow to muscles increases, and production of adrenaline and other powerful hormones rises. This last aspect of the body's response to stress has an immediate impact on appetite and immune function: both are suppressed. Appetite disappears as blood is diverted from the stomach and intestine to skeletal muscles, and the function of infection-fighting white blood cells is suppressed in order to maximize the circulation of oxygen-carrying red blood cells.

The immunologic impact of sustained stress

These physiological responses to psychological stress are not harmful to the body over the short term. Indeed, most experts feel that a certain amount of short-term stress can even be beneficial to the body, similar to the effects of moderate physical exercise. However, sustained and unrelenting psychological stress -- especially stress related to issues of safety, security, and survival -- does begin to take a toll on the body:

  • Diminished appetite and disrupted digestion eventually cause partial malnutrition, weight loss, reduced overall vitality, and decreased immune function

  • Repeated disturbance of sleep patterns produces a jet-lag-like condition that leads to suppressed immune function

  • Sustained survival stress results in immune system inhibition, and eventually causes erosion of immune function

Intense, unresolved grief can weaken immunity

Grief is the natural emotion that one feels after the loss of someone, or something, important. Grief can result from the loss of a parent, family member, lover, or friend. Death is the most obvious and most traumatic loss, but divorce and the break-up of a relationship are also forms of loss. Grieving can be intense for losses other than people: for loss of a job and the special status it brought; for loss of a natural ability (e.g., the loss of one's sight); for loss of a major life convenience (e.g., driving one's own car); for loss of financial security; even for the loss of a beloved pet. After a significant loss, grieving is natural and normal. It is also psychologically necessary: it rebalances us emotionally and allows us to return to normal life. It is completely normal to be plunged into grief after a significant loss, to experience that grief and its life-disrupting effects for a time, and then to put the grief aside. Intense grieving that lasts longer than three to six months is considered atypical, and if you find you are still experiencing unresolved grief half a year after a loss, you should seek the help of a professional counselor.

"Survival stress and unresolved grief are but two of the many psychosocial factors that can have an adverse impact on immune function -- and anything that compromises immune function is a matter of serious concern to anyone whose immune system is already severely compromised by the insidious effects of HIV infection."

Protracted, unresolved grieving has an especially burdensome impact on the immune system. Studies have shown that even the normal three-to-six-month grieving process impedes immune function to the extent that illness is more likely during the grieving period. When researchers studied a group of HIV-positive men who had recently suffered the loss of a life-partner, they found that the immune systems of the bereaved men exhibited changes that are strongly associated with disease progression and the development of AIDS.

Other psychosocial factors that affect immune function

Survival stress and unresolved grief are but two of the many psychosocial factors that can have an adverse impact on immune function -- and anything that compromises immune function is a matter of serious concern to anyone whose immune system is already severely compromised by the insidious effects of HIV infection. In the last five years teams of investigators have identified a number of purely psychological factors that can have a negative impact on immune function and hasten disease progression (Table). Among them are: a morbid fixation on death and dying as the inevitable outcome of HIV infection, clinical depression, the absence of a sense of purpose in life (coupled with a lack of short- and long-term goals), an inability to assert oneself or to act decisively and effectively on one's own behalf, and poor coping skills in times of crisis.

Having trustworthy sources of support -- in the form of friends and family, spouses, lovers, and life-partners -- has been shown to be immune-enhancing. Conversely, the absence of such support has a negative impact on the immune system. One recent study showed that men with HIV who lacked strong social support tended to die sooner from AIDS.

It should come as no surprise that gay men who conceal their sexual orientation progress to AIDS faster than those who are open about their affectional preference. Many stressors come into play here, of course, but a principal difference is that "closeted" homosexuals with HIV disease have practically no social support, whereas "out" homosexuals, especially those living in cities that have an active gay community, are buoyed by a social support system that includes everything from counseling services and "buddy" programs to legal aid and hot meals delivered to their door.

"To live in an AIDS-afflicted community is to live in a world of unremitting grief and unabated survival stress. For gay men, for inner-city women of color, for hemophiliacs and IV drug users, the loss of loved ones is not occasional, it is unrelenting -- an unending cascade of loss and grief that often defies the best efforts of the strongest personalities to restore enthusiasm, optimism, and purpose to their lives."

It should also come as no surprise that people with HIV disease who fail to take good care of themselves also experience a more rapid onset of AIDS. Individuals who do not consume an adequate number of calories, who skip meals, or who fail to eat nutritionally balanced meals are at risk for the so-called AIDS wasting syndrome. Recent research indicates that poor nutrition and diminished appetite further suppress an HIV-positive person's already suppressed immune system. When people with HIV do not sleep well, abuse alcohol and drugs, and/or get little or no vigorous physical exercise, immune function can be further eroded.

We now recognize that survival stress, grief, a morbid fixation on death and dying, clinical depression, and the absence of a sense of purpose are all risk factors for further suppression of immune function and for progression to AIDS. Researchers have measured the impact of each of these stressors on people with HIV disease. But how can we assess the cumulative, compounding impact of all of these factors over many years? To live in an AIDS-afflicted community in the last decades of the twentieth century is to live in a world of unremitting grief and unabated survival stress. For gay men, for inner-city women of color, for hemophiliacs and IV-drug users, the loss of loved ones is not occasional, it is unrelenting -- an unending cascade of loss and grief that often defies the best efforts of the strongest personalities to restore enthusiasm, optimism, and purpose to their lives.

Psychosocial Factors That Can Have a Negative Effect on Immune Function
Psychological Factors

  • Preoccupation with death and dying

  • Chronic impatience

  • Sustained survival stress

  • Protracted, unmanaged grieving

  • Clinical depression

  • Lack of purpose and goals

  • Lack of self-assertiveness

  • Lack of emotional support (or inability to accept support)

  • Poor coping ability
Behavioral Factors

  • Restricted breathing patterns (shallow breathing, breath-holding)

  • Inadequate fluid intake (partial dehydration)

  • Poor appetite, eating habits, and/or nutrition

  • Insufficient or disrupted sleep

  • Substance abuse, exposure to toxins

  • Inadequate or inappropriate exercise
Healthcare Factors

  • Repeated exposure to HIV and other infections

  • Limited capacity for self-care when sick

  • Limited involvement in/understanding of HIV-related health issues

  • Passive, uninformed relationship with primary care providers

How you can reduce the level of stress in your life

It is important to know that stress consumes CD4 cells. And everyone who is HIV-positive -- those who were diagnosed last week, those who have been on antiretroviral therapy for a decade, and all those in between -- should take steps to lower their stress levels. This be can done. The stress of living with HIV can be reduced by means of specific interventions just as effectively as viral load can be reduced by means of combination antiretroviral therapy. To help you achieve this all-important goal, we have provided some general guidelines for stress reduction -- which you will find in the box below.

We have also provided some very specific suggestions for ways you can alleviate certain specific sources of stress that are common to all people living with HIV. You will find those recommendations in the special Pull Out and Save section of this issue, "What You Can Do to Reduce the Level of Stress in Your Life."

Your primary care providers, working with psychologists and counselors, can help you cope with the stress of living with HIV -- but only if you recognize that you are under stress and ask for help in managing it. Take depression, for example. It is both a symptom of stress and a cause of stress. Indeed, it is one of the most common manifestations of sustained stress -- and one of the most treatable. Yet depression often goes untreated in people with HIV, in part because providers fail to diagnose it, in part because patients themselves fail to recognize its symptoms.

There are several reasons for the frequency with which depression goes undiagnosed and untreated in people with HIV disease. For one thing, many of the classic symptoms of depression -- fatigue, sleep disturbances, decreased libido, impaired concentration -- are also common to symptomatic HIV disease itself. As a result, these symptoms can be incorrectly attributed to advancing infection rather than to depression.

Another reason that depression goes undiagnosed and untreated is that many caregivers incorrectly assume that demoralization, a profound sense of hopelessness, and loss of direction, purpose, and self-esteem -- all symptoms of depression -- are "normal" emotional responses to the harsh realities of living with HIV and therefore require no treatment. Given this pervasive belief, it cannot be stressed too often or too emphatically that chronic depression is never normal. Rather, depression is a set of physical symptoms and altered moods that can be attributed, at least in part, to abnormal biological processes. Recognizing the symptoms of depression, and treating both the symptoms and their biological causes, will therefore benefit virtually all depressed individuals.

Drug therapy is now a standard treatment for clinical depression, and the advent of newer, safer, better-tolerated antidepressants has given providers many therapeutic options. No specific agent or class of agents has been shown to be particularly effective in people with HIV disease, but all of the widely used antidepressants can be effective in these individuals.

All people with clinical depression also need regular counseling, whether they are taking antidepressants or not. While the primary care provider is in a good position to initiate this process, depressed individuals can benefit from the service of a therapist who is familiar with HIV disease. Standard, open-ended psychotherapy may not be appropriate for those whose time, energy, and finances are limited, but short-term, goal-oriented therapy has been shown to be helpful.

We know that aggressive intervention, with a combination of drug therapy and psychotherapy, can improve the outlook of depressed individuals and relieve the sustained survival stress seen in people living with HIV. This knowledge led a number of researchers to wonder if a well-designed stress-reduction program, by reducing stressors in these patients' lives, could boost immune function, reduce HIV-related symptoms, and improve longevity? The answer is an emphatic "yes": we now know that such programs can increase immune function and improve both the physical and mental health of HIV-positive individuals.

What You Can Do to Reduce Stress in Your Life

  • Understand the mind-body link in HIV disease. As studies now show, you can conserve -- and perhaps even restore -- your immune system by reducing the number and level of stressors in your life. (For a list of those stressors, and specific suggestions for how to combat them, see the special Pull Out and Save section of this issue, "What You Can Do to Reduce the Level of Stress in Your Life.") This understanding counters the fatalistic belief that HIV infection results in steady erosion of the immune system and leads inevitably to death. It also provides a source of inspiration and motivation, one that will help you take the steps you need to take to reduce your stress level.

  • Assess your personal "stress profile." Carefully consider the 19 stress factors listed in the Pull Out and Save section of this issue. Determine which factors most affect you, and gauge whether your performance in each of those specific areas is in some way lacking or inadequate. Make a list of the areas in which you are weakest. This will help you to focus your stress-reduction efforts.

  • Correct your weaknesses. Adopt and adapt the suggestions contained in the pull out and save section to improve your cofactor performance. Understand that consistency is important; an all-or-nothing, one-time effort will not correct the causes of stress in your life. If possible, enlist the help of a "buddy" -- someone who is as determined to reduce life's stress as you are. Support and encourage one another's efforts.

  • Get help. Stress is multifactorial, so it is hard to assess and correct all of life's stressors on one's own. It helps to get professional help. Make use of all of the counseling services and support networks in your area. (For a state-by-state list of AIDS service organizations, see the Pull Out and Save feature in the August 1997 issue of AIDS Care.) Find a counselor who will assist you in your efforts to overcome the chief sources of stress in your life.

  • Learn to see the big picture. Avoid thinking of treatment for HIV disease in a simplistic, either-or fashion: either medical or psychological, either conventional or alternative. Treatment is maximally effective when it combines potent antiretroviral medications with immune-boosting psychological interventions. Think of your primary care providers and your counselor as a treatment partnership, one that maximizes your chances of remaining healthy and clinically stable.

A model stress-reduction program

In the last five years several groups have crafted programs designed to change behavior, enhance immunity, moderate symptoms, and increase longevity in people living with HIV. Model treatment programs for HIV-positive people are now being run at the University of Miami's Center for Biopsychosocial Studies of AIDS, at the L.I.F.E. Program of the San Diego Lesbian & Gay Men's Community Center, and at Harvard Medical School's Mind/Body/Spirit Program for HIV/AIDS (see box in the Pull Out and Save section of this issue).

"Comprehensive treatment programs can have an appreciable impact on stress levels and immune function in participants who complete these courses. These stress-reduction programs can change behavior, enhance immunity, moderate symptoms, and increase longevity in people living with HIV."

The L.I.F.E. Program, which I helped develop, is an acronym for Learning Immune Function Enhancement. This program teaches HIV-positive individuals how to assess their performance on 19 psychosocial cofactors that can affect immunity and/or HIV disease progression (see the pull out and save feature in this issue). Participants attend weekly group-counseling sessions for three months and then receive individual counseling on a weekly basis for an additional three months. Thereafter they are welcome to participate in a L.I.F.E.-run support group for as long as they want. The goal of the group and individual counseling sessions, and of the follow-up support program, is to enable L.I.F.E. participants to develop and implement strategies that will improve their performance in those psychosocial areas where weak performance puts them at risk.

Comprehensive treatment programs like the L.I.F.E. Program can have an appreciable impact on stress levels and health behaviors in participants who complete these courses. In our own program, roughly 70% of successful graduates report significant reductions in psychological distress and in behaviors that adversely affect immune function. About 60% of these successful graduates also report reductions in stress-related physical symptoms, chiefly gastrointestinal complaints.

Recent research suggests that the successful management of these psychological factors can lead to symptom reduction -- which helps conserve immune function. The evidence now shows that comprehensive stress-reduction programs can indeed change behavior, enhance immunity, moderate symptoms, and increase longevity in people living with HIV.

Jeffrey M. Leiphart, Ph.D., is Director of HIV Prevention Services at UCSF AIDS Health Project, San Francisco, CA

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This article was provided by San Francisco General Hospital. It is a part of the publication AIDS Care.