People with HIV and those close to them are subject to numerous stressors that can impact their mental health. Among these stressors are fear and anxiety following the initial disclosure of HIV seropositivity, stressful and confusing medical treatment regimens, the prospect of serious medical problems, and the sadness and grief associated with having a foreshortened future. Thus, HIV-affected individuals are challenged to find ways of coping with stress, anxiety, and feelings of depression throughout the course of HIV disease. A person's history of coping with adversity or illness, the amount of social and emotional support they receive from friends, family, and community organizations, and their ability to access mental health services can all be important protective factors for an HIV-affected person's mental health.
The impact on one's mental health of HIV-related psychosocial stressors (those that cause stress associated specifically with one's social relationships) can be quite significant. For example, frequent episodes of bereavement following the loss of friends, partners, family members, and associates can cause acute or chronic feelings of depression. Children may suffer from emotional and behavioral difficulties, as well as learning problems, as a result of poor adjustment to the loss of parents and other caregivers to HIV disease. The stigma associated with being HIV-positive and the need to keep one's HIV status a secret from family, friends, and coworkers can lead to feelings of social isolation and depression. The need to conceal HIV-related changes in one's ability to function at work and the pressure to consider making changes such as going on disability can also be a source of depression and anxiety.
Initiating and maintaining romantic and sexual relationships are an additional source of anxiety for the HIV-infected individual, who may struggle with the disclosure process and be preoccupied with concerns about HIV transmission to his or her partners or reinfection with HIV. Given the increase in the number of serodiscordant couples (partners with opposite HIV statuses) in recent years, these concerns have been observed with greater frequency, as have issues relating to future planning, caretaking, fear of abandonment, lack of sexual spontaneity and satisfaction, and survivor guilt.
The psychiatric manifestations of HIV/AIDS encompass a broad spectrum of clinical presentations. A number of these are discrete neurological conditions. Other conditions include mood and anxiety disorders, impairments in cognitive and motor functioning, and alterations in personality and behavior. The assessment of psychiatric disturbance in patients with HIV/AIDS is complicated by the many possible underlying etiologies for these disturbances, including the direct and indirect impact of HIV on the central nervous system, the impact of medical illness, and preexisting psychiatric illness, as well as the psychological distress and adjustment difficulties discussed previously. A diagnosis of psychiatric disorders in patients with HIV/AIDS must involve a careful analysis of common overlapping symptom clusters associated with HIV-related medical illnesses and their treatment and with certain psychiatric disorders.
Psychiatric disorders may either have physical, medical, or genetic origins, or they may emerge as the result of an emotional or psychological response to acute or chronic life stressors; most psychiatric disorders involve a combination of the two. The treatment of psychiatric disorders may involve medication, psychotherapy, or a combination of both.
The current classification system for psychiatric disorders, the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association, the fourth edition of which (DSM-IV) was published in 1994, specifies symptom clusters necessary to make psychiatric diagnoses. In this system, an individual may experience some of the symptoms of a particular disorder but not meet criteria for a diagnosis. It does not mean, however, that this individual is not experiencing distress and does not warrant some form of treatment or is not in need of additional social support. The diagnostic categories outlined in DSM-IV are meant as a guideline to enable clinicians and investigators to reliably diagnose, communicate about, and treat various mental disorders with some uniformity.
Although many DSM-IV diagnostic categories include "significant impairment in social or occupational functioning" as a necessary criterion for giving a diagnosis, the categories may not be wholly relevant to legal or clinical judgments about disability determination, competency, and quality of life, which are salient to persons with HIV/AIDS. Since the onset of the AIDS epidemic, psychiatric epidemiologists have turned their attention to examining the prevalence of psychiatric disturbances in HIV-infected individuals, in particular major depression, suicidality, and anxiety disorder.Major depression refers to a cluster of symptoms, such as sleep disturbance, loss of appetite, lethargy, and loss of libido, which coincide with a persistent depressed or sad mood or a chronic loss of interest in pleasurable activities (anhedonia), lasting for a period of at least two weeks. It is estimated that the lifetime prevalence of major depression in the United States is between 10 and 20 percent. Early estimates of the prevalence of depression in persons with HIV/AIDS, based not on these relatively stringent clinical diagnostic criteria but on research using self-reported symptom checklists, were found to be quite high, reaching 20 percent in some studies. Subsequent research, using interviews administered by trained clinicians, has revealed significantly lower estimates of depression in persons with HIV/AIDS. For example, one controlled study suggested that the rate of depression in a sample of HIV-positive gay men was not significantly different from that of a comparison group of HIV-negative gay men but was slightly higher than the rate in the general population.
Although depressive disorders seem to be no more prevalent or normative in persons with HIV/AIDS, mild depressive symptoms appear to be more common. Clinicians working with persons with HIV/AIDS have been careful to point out that transient mood changes are frequent in this population because of life stressors that are significant in terms of mental health and quality of life, but these mood changes must be differentiated from clinical depression. Examples include multiple episodes of mourning as friends and partners die, sadness associated with the prospect of a foreshortened life, and stress associated with discrimination and social stigma.
Also of particular importance in assessing and treating depression in persons with HIV/AIDS is the difficult task of differentiating symptoms of depression that overlap the physical symptoms of HIV/AIDS. For example, fatigue, weight loss, sleep disturbance, and low libido are classic symptoms of major depression but are also common nonspecific signs of HIV-related medical illness. Further, the clinician must evaluate whether putative depressive symptoms predate HIV infection; this requires taking a careful psychiatric and family history when doing an assessment. Also, any assessment of depression in persons with HIV/AIDS must take into consideration that depressive symptoms may arise primarily as a result of alcohol or substance abuse or may emerge as a consequence of HIV-related neurological impairments. Finally, suicidality, or serious contemplation of taking one's own life, is a common clinical feature of major depression, but it may also emerge in persons with HIV/AIDS as a rational coping response in the later stages of disease progression and may not indicate an underlying depression.
Several studies have shown an increase in the frequency of suicidal thoughts and attempts for persons with HIV. Suicidal feelings often arise when an individual is depressed, but in the case of HIV, the ability to entertain suicide as a rational option in the face of the possibility of acute suffering or debilitating illness may offer the person with HIV a sense of control over an uncertain future. The risk that a person with HIV/AIDS will actually attempt suicide appears to be correlated with a history of psychiatric treatment, substance abuse, HIV-related interpersonal and work difficulties, and the perception of inadequate social support.
The anxiety disorders outlined in DSM-IV include generalized anxiety disorder, phobias (agoraphobia, simple phobia, social phobia), post-traumatic stress disorder, panic disorder, and obsessive-compulsive disorder. Any of this diverse group of disorders, which involve acute or chronic anxiety, is sufficient to cause both a significant pathological level of distress and an impairment in functioning. It is estimated that the lifetime prevalence of anxiety disorders in the United States is between 10 and 15 percent. Although there have been a number of reports which suggest that elevations in anxiety levels, often lasting up to several months, are common in the course of HIV infection, diagnosable anxiety disorders appear to be no more prevalent in persons with HIV/AIDS than in the general population. Although symptoms of anxiety in persons with HIV disease may not satisfy criteria for a psychiatric diagnosis, they may nonetheless cause significant distress and require treatment.
Cadwell, S. A., S. A. Burnham, and M. Forstein, eds., Therapists on the Front Line: Psychotherapy with Gay Men in the Age of AIDS, Washington, D.C.: American Psychiatric, 1994.
Odets, Walt, and Michael Shernoff, eds., The Second Decade of AIDS: A Mental Health Practice Handbook, New York: Hatherleigh, 1995.
Rabkin, J., R. Remien, and C. Wilson, Good Doctors Good Patients: Partners in HIV Treatment, New York: NCM, 1994.
Wicks, Lucy A., Psychotherapy and AIDS: The Human Dimension, Bristol, Pennsylvania: Taylor and Francis, 1997.
Winiarski, M. G., AIDS-Related Psychotherapy, New York: Pergamon, 1991.
Encyclopedia of AIDS $25 US/832 pp/Illustrated
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The Encyclopedia of AIDS: A Social, Political, Cultural, and Scientific Record of the HIV Epidemic, Raymond A. Smith, Editor. Copyright © 1998, Raymond A. Smith. Carried by permission of Fitzroy Dearborn Publishers.
Encyclopedia of AIDS $25 US/832 pp/Illustrated
For more about this book, or to order, click here.