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Psychosomatics 39:350-359, August 1998
© 1998 The Academy of Psychosomatic Medine

Coping Styles and Psychosocial-Related Variables in HIV-Infected Patients

Luigi Grassi, M.D., Roberto Righi, M.D., Laura Sighinolfi, M.D., Shariar Makoui, M.D., and Florio Ghinelli, M.D.

Received April 11, 1997; revised August 6, 1997; accepted August 19, 1997. From the Department of Medical Sciences of Communication and Behavior, Section of Psychiatry, the Consultation-Liaison Psychiatric Service, University of Ferrara, Italy; and the Division of Infectious Diseases, St. Anna Hospital, Ferrara, Italy. Address reprint requests to Dr. Grassi, Clinica Psichiatrica Università di Ferrara, Corso Giovecca 203, 44100 Ferrara, Italy. E-mail: L.grassi{at}dns.unife.it


  ABSTRACT

 
TOP
 ABSTRACT
INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
The study examined the relationship between coping and psychosocial variables (psychological stress symptoms, locus of control, emotional repression, and social support) among 108 human immunodeficiency virus (HIV)-infected patients. The authors administered several tests, including one that measures fighting spirit and degree of hopelessness, to assess each patient's individual coping style. The patients who were adjusting well to their HIV-positive status tended to have a higher level of fighting spirit and lower degree of hopelessness than those patients who were not adjusting well to their HIV-positive status. A coping style based on incapacity to face and confront HIV infection was associated with symptoms of psychological stress, repression of anger, external locus of control, and low social support in the latter group. These patients showed symptoms indicating maladjustment to HIV infection (43% of the sample) and differed from the "noncases" (the well-adjusted patients) in that the former group reported inadequate coping responses (lower fighting spirit and higher hopelessness, fatalistic attitude, and anxious preoccupation) and poorer social support, and had a greater tendency to repress anger and express sadness. The data support the hypothesis that coping with HIV infection is a complex phenomenon involving multiple and interacting variables. Interventions aimed at improving the coping style for many HIV patients are needed.

Key Words: AIDS • HIV • Coping • Adjustment

  INTRODUCTION

 
TOP
 ABSTRACT
 INTRODUCTION
METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
Research investigating and documenting psychosocial consequences of human immunodeficiency virus (HIV) infection has accumulated during the past two decades. Several studies have pointed out that psychiatric disorders may be diagnosed in a high percentage of HIV-infected patients and that several variables, ranging from medicobiological to psychosocial ones, intervene in facilitating the onset of emotional disturbances secondary to HIV infection.1–3 With reference to this fact, the relationship between coping and psychosocial morbidity represents a field of specific interest in HIV and AIDS literature. Coping, defined as the cognitive and behavioral efforts made by a person to alter or manage the problem(s) caused by a specific stressful situation,4 has been repeatedly studied in HIV-infected subjects. From a psychosocial perspective, it has been documented that coping styles greatly influence the psychological impact of HIV infection. Early reports indicated that active behavioral coping strategies were related to lower mood disturbances in HIV-infected patients,5,6 whereas avoidant coping was associated with higher emotional stress.7 These data have been confirmed by more recent research,8–11 which also showed significant interactions between less effective coping styles and several variables, such as low social support;6–8 personality factors (e.g., poor self-esteem, low control);12 and high occurrence of stressful events.13, 14 Furthermore, effective coping has been found to be related with better quality of life15 as well as reduction of risk-taking behavior.16,17 From a psychobiological perspective, the way in which HIV-infected subjects respond to their condition might also have a role in molding disease parameters. In fact, some studies of HIV-infected patients have shown that active coping was associated with higher total lymphocyte, CD4+, and "Natural Killer" cell counts18,19 and that a rapid progression of HIV disease was more likely in patients who adopted a passive20 or fatalistic–resigned coping style,21 particularly if associated with depression and occurrence of severe stressful events.22–24 Given these findings, a specific constellation of coping, developed from psycho-oncology research and known as the "fighting spirit–hopelessness dimension" could be a particularly promising area for future research in the HIV setting. Several studies of patients with cancer have shown that fighting spirit is associated with low levels of emotional symptoms, whereas hopelessness is related to a higher prevalence of psychological morbidity.25–29 Furthermore, adoption of a fighting-spirit coping style seems to be influenced by personality factors (e.g., internal locus of control, low repression of anger) and adequate social support.27,30,31 Last, cancer patients who use a fighting-spirit coping style have been found to survive longer than those showing fatalistic attitudes (stoic acceptance) or hopeless responses in prospective studies.32,33 In consideration of the fact that cancer and HIV diseases present areas that overlap at both psychosocial (e.g., psychiatric morbidity, death issues, palliative care)34–38 and biological (involvement of immune system, chemotherapy protocols, risk of cancer in HIV-positive patients) levels, we decided to extend analysis of this coping construct to patients with HIV infection. In a pioneer research exploring coping through this specific framework, Leserman et al.39 found a significant association between fighting spirit and less dysphoria, higher self-esteem, and more satisfaction with one's own social support system.

The main aim of the present study was to evaluate the association of coping, particularly the fighting spirit–hopelessness dimension, with psychological stress symptoms, social support, and personality variables.


  METHODS

 
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
RESULTS
 DISCUSSION
 REFERENCES
 
Subjects
A series of HIV-infected outpatients at the Division of Infectious Diseases, St. Anna Hospital, Ferrara, Italy, between 1993 and 1995 participated in the study during one of the patients' scheduled medical visits. Recruitment criteria were 1) an age between 18 and 60 years; 2) a score >=80 on the Karnofsky Performance Status Scale (KPS),40 indicating normal capacity in carrying on daily life; and 3) intact cognitive functioning, as measured by a short neuropsychological screening test.41 All the subjects were informed of the study's aims and asked to give their informed consent by the doctor visiting them, who performed a routine physical examination. Blood samples were also obtained during the visit to evaluate the patient's immunological status. After that, each subject was individually met by a psychiatrist and given a psychosocial assessment battery, consisting of self-report questionnaires to evaluate coping, psychological stress symptoms, social support, and personality variables (external locus of control and emotional repression). Data on route of infection; clinical status, according to the Centers for Disease Control and Prevention (CDC); and time since notification of seropositivity were extracted from the patient's medical charts. The patient's immunological data consisted of the results of the blood assay obtained at the same visit in which the psychosocial evaluation was made.

Measures
Coping was evaluated through the Mental Adjustment to Cancer (MAC) scale,42 a 40-item self-report questionnaire originally developed in the oncology setting and recently used with HIV-positive patients,39,43 to assess cognitive and behavioral coping toward illness. The patients were instructed to read the list of 40 statements describing "people's reactions to having HIV infection" and rate each item on a four-point scale, ranging from 1 ("definitely does not apply to me") to 4 ("definitely applies to me"). The MAC scale consists of four subscales: 1) "Fighting Spirit" indicates the tendency to confront and actively face the illness, adopting a positive and determined attitude (e.g., "I try to fight the illness," "I see my illness as a challenge"); 2) "Hopelessness" measures the patient's tendency to adopt a pessimistic attitude and to feel hopeless about the illness (e.g., "I feel I can't do anything to cheer myself up," "I feel like giving up"); 3) "Anxious Preoccupation" evaluates feelings of anxiety and tension concerning the illness (e.g., "I suffer a great anxiety about it," "I feel that problems with my health prevent me from planning ahead"); and 4) "Fatalism" indicates resigned and fatalistic attitudes about the illness (e.g., "I put myself in the hands of God," "I feel fatalistic about it"). Since in the original study,42 fighting spirit and hopelessness were inversely related and contributed to the same dimension in the factor analysis (bipolar dimension with "fighting" responses loading positively and "hopeless" responses loading negatively), the authors44 also consider the utility of maintaining this subscale by subtracting the "Hopelessness" score from the "Fighting Spirit" score (FS-H score), to yield a measure of effective coping to illness (higher scores corresponding to better coping).

Symptoms of psychological stress were assessed with the Brief Symptom Inventory (BSI).45 The BSI is a 53-item questionnaire with each stress-symptom item rated on a five-point scale (from 0=not at all to 4=very much). Nine primary dimensions are yielded: 1) somatization, 2) obsessive-compulsivity, 3) interpersonal sensitivity, 4) depression, 5) anxiety, 6) hostility, 7) phobic anxiety, 8) paranoid ideation, and 9) psychoticism. A score on the Global Severity Index (GSI) (score sum/53), as a general score of distress, is also computed. As recommended,45 cut-off T-scores >=63 on the GSI or on two primary dimensions were used to identify patients with substantial levels of psychological symptoms, and they were classified as poor adjusters ("cases"), whereas those patients who were adjusting well were classified as "noncases."

External locus of control, indicating the individual tendency to attribute the course of one's life to chance, fate, or uncontrollable causes, was measured through a seven-item self-report version of the Rotter Locus of Control scale (ELC-S).46

The individual tendency to inhibit behavioral expression of negative feelings (emotional repression) was evaluated by the Courtauld Emotional Control Scale (CEC-S).47 This is a 21-item multiple-choice questionnaire that yields scores on three emotional control subscales (Anger, Anxiety, and Depression) and a Total Control scale score.

The Social Provision Scale (SPS)48 was used to assess the extent of support from family, friends, and interpersonal relationships in general. The SPS is a 24-item multiple-choice questionnaire that measures social support on six distinct subscales: Attachment, Social Integration, Reassurance of Worth, Reliable Alliance, Guidance, and Opportunity for Nurturance, as well as yields a Total Support scale score.

Statistical Analysis
Data were analyzed by using the Statistical Package for Social Sciences.49 Students' t-test for independent samples, one-way analysis of variance (ANOVA), Pearson correlation test, {chi}2 test, and multiple regression analysis were used when appropriate. To avoid the likelihood of a Type 1 error, only differences or correlations significant at P<0.01 were interpreted.


  RESULTS

 
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
DISCUSSION
 REFERENCES
 
Patient Characteristics
There were 108 subjects (73 males and 35 females) with a mean ± standard deviation (SD) age of 32.04 ± 7.50 years. Most patients were married (60.9%) and employed (51.8%). With regard to probable mode of HIV infection, 75 subjects were infected through intravenous drug use (IVDU) (64.5%), 34 were infected through sexual intercourse with an HIV-positive partner (19 homosexuals=17.3%, 15 heterosexuals=13.6%), and 1 was infected through a blood transfusion (0.9%). It was not possible to record the cause of infection for three patients (3.6%). According to the CDC system of disease classification, 35 subjects were in CDC Group 2 (31.8%), 53 in CDC Group 3 (48.2%), and 22 in CDC Group 4 (20%). Mean ± SD time since notification of seropositivity was 18.31 ± 15.60 months (range: 3–78 months). CD4+ cell counts ranged from 4 to 985/mm3 (mean ± SD: 194.7 ± 221.3), and CD8+ cell counts ranged from 69 to 1020/mm3 (mean ± SD: 689 ± 546).

Coping Style and Related Variables
Evaluation of the association between the FS–H score and the psychosocial variables examined is presented in Table 1. FS–H was significantly negatively correlated with external locus of control (ELC-S) (P<0.01), CEC-S anger (P<0.001), and psychological stress symptoms (all correlations P<0.001, with the exception of Anxiety and Hostility) and, positively, with certain dimensions of social support (Social Integration, Reassurance of Worth, Opportunity for Nurturance, and Total Social Support, P<0.01). Correlation with medical variables was not significant (CD4+ r=-0.03, CD8+ r=-0.02, CD4+/CD8+r=-0.01, time since diagnosis r=-0.08). FS–H score was independent of CDC status (ANOVA F= 0.63) and "at-risk" category (ANOVA F=0.34).


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TABLE 1.



Multiple regression analyses were conducted in which the dependent variable (FS–H score) was regressed on the psychosocial variables (CEC-S Anger, Anxiety, and Depression and ELC, GSI, and Total Social Support). The factors together explained 90% of the variance (Adjusted R2=0.83, P<0.01). Stepwise multiple regression showed that the GSI was the most important factor in predicting FS–H score, accounting for 57% of the variance (Adjusted R2=0.54, ß=-0.66, P<0.01, indicating that an increased GSI score is associated with less effective coping. CEC-S Anger accounted for an additional 17% of the FS–H score variance (ß=-0.41, cumulative variance 74%, Adjusted R2=0.69, P<0.01), indicating that higher repression of anger is associated with less effective coping. Since some of the independent variables were intercorrelated, specifically Total Social Support with CEC-S Anxiety (r=-0.61), CEC-S Depression (r=-0.54) and, moderately, GSI (r=-0.34), as well as ELC with CEC-S Anger (r=-0.52) and CEC-S Anxiety (r=-0.56), further analyses were conducted after removing Total Social Support and ELC from the equation. No change was found in the results, with GSI and CEC-S Anger still statistically predicting FS–H score (Adjusted R2=0.69, P<0.01).

Differences Between Nonadjusters and Adjusters: "Cases" vs. "Noncases"
A further analysis was conducted to compare the patients who adjusted well to their HIV condition ("noncases") with those who adjusted poorly ("cases"). According to the BSI cut-off T-scores, 47 subjects (43.5%) showed maladjustment symptoms (classified as "cases") and 61 (56.5%) were adjusting well (classified as "noncases"). Comparisons between these two groups are shown in Table 2. By examining all the MAC coping scales, the "cases" showed higher scores on Hopelessness, Anxious Preoccupation, and Fatalism scales and lower scores on Fighting Spirit. CEC-S Anger was moderately higher in the "cases," whereas CEC-S Depression was higher in the "noncases." Lower scores on several social support dimensions (Reliable Alliance, Reassurance of Worth, and Total Social Support) were found among the "cases," compared with higher scores for the "noncases." The "cases" differed also from the "noncases" in that the former had been diagnosed with HIV for a longer time period compared with the latter (mean ± SD: 24.6 ± 16.79 vs. 19.94 ± 14.13 months, P<0.01).


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TABLE 2.



These data were confirmed by correlation analysis. The GSI was moderately associated with Total Social Support (r=-0.34, P<0.01) and significantly with MAC anxious preoccupation (r=0.39, P<0.01), fatalism (r=0.37, P<0.01), hopelessness (r=0.62, P<0.01), fighting spirit (r=-0.45, P<0.01), and FS–H SCORE (r=-0.57, P<0.01). No association was found with CDC stage (r=0.10) and lymphocyte cell counts (CD4+ r=-0.07, CD8+ r=-0.10, CD4+/CD8+ r=-0.08).


  DISCUSSION

 
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
REFERENCES
 
In this study, we investigated the relationship between coping styles, with particular reference to the fighting spirit–hopelessness construct, and psychosocial variables in HIV-infected patients.

A first result was that the FS–H score, as a measure of active coping with HIV infection, was associated with several psychosocial factors. Psychological stress symptoms (i.e., phobic anxiety, depression); personality factors (i.e., external locus of control and repression of anger); and low social support were in fact related to a less effective coping style (lower FS–H score). These findings confirm and bolster prior results that showed a significant association for passive and/or maladaptive coping strategies with mood disturbance,7–11 poor social support,6,8 and personality traits characterized by low control and poor self-esteem12 in HIV-infected patients. However, in the regression model evaluating the role of the different psychosocial variables examined in predicting coping level (FS–H score), only psychological stress (global stress index) and anger repression were predictors of a poor ability in the patients to deal with HIV infection. The role of repression and anger is noteworthy, since both have rarely been explored in persons living with HIV. Interestingly, our results mimic the findings derived from other studies of cancer patients, in whom the tendency to repress negative feelings, such as anger, was related to both higher levels of depressive disturbance30 and ineffective coping, as measured by the same FS–H construct.27

A second result of the study, confirming the aforementioned findings, regards the differences between the patients showing symptoms of maladjustment ("cases": 43% of the entire sample) and those who were adjusting well to their HIV status ("noncases"). The former group reported less effective coping strategies, as shown both by lower scores on Fighting Spirit and higher scores on Hopelessness, Anxious Preoccupation, and Fatalism than the adjusters. Again, a pattern characterized by marked tendency to repress feelings of anger and inability to control sadness was shown among the "cases." In agreement with other research reports,50–53 the role of social support was also important in differentiating the patients with significant psychological morbidity ("cases") from those with none to minimal morbidity ("noncases."). The "cases" perceived a lack of reliable alliance within their interpersonal relationships, less intense guidance in making choices, and less reassurance about their worth as persons. The fact that the number of months since HIV notification was longer among the "cases" confirms research reports that have demonstrated a significant association between time since diagnosis and maladaptive response to HIV infection.7,54 However, the patients who were in the more advanced stage of HIV infection (CDC stage and low CD4+ cell count) did not significantly differ on coping measures and psychological stress symptoms from those in the early phases of illness. Although this result is in contrast with other research reporting that depressive symptoms and maladjustment to illness tend to increase with the development of acquired immunodeficiency syndrome (AIDS),55,56 our results are consistent with other studies showing that patients with low CD4+ cell count and/or AIDS are not necessarily more depressed than those in the early phases of infection.57–61 Further research is needed to better understand this specific finding.

Taken together, the results of our study that we have presented confirm that several variables, namely emotional distress symptoms, inability to express anger, poor support, and lack of interpersonal ties, interconnect and play a role in determining the way in which HIV-infected patients respond cognitively and behaviorally to their disease. Clinical implications of these findings in HIV-infected patients are apparent. First, given the relatively slow natural progression of HIV infection and increased survival determined by recent medical therapies, the regular assessment of these psychosocial variables should be a mandatory component of medical care in HIV settings, so that patients who indicate dysfunctional coping skills are referred to appropriate services. Second, a bulk of studies in oncology settings have demonstrated that psychological interventions that promote the expression of negative feelings (i.e., anger) and the development of effective coping strategies (i.e., fighting spirit) significantly improve psychological status62 and, possibly, increase survival time.63 Third, the possibility that HIV-positive subjects who present symptoms of psychological stress and repress their feelings of anger tend to alleviate their discomfort by risk-taking behavior (e.g., unprotected sex, drug use, sharing needles) represents a major challenge in therapeutic settings. In fact, recent reports indicate that emotional disturbances, passive coping, and difficulty in showing one's own feelings, including anger, were related to both high risk-taking behavior17,64,65 and worse prognosis (reduction of CD4+ cells, progression to the symptomatic AIDS phase, development of cancer)20,21,66 in subjects with HIV infection.

Certain caveats, however, are in order because of limitations of this study. Because of the cross-sectional nature of the study, no conclusions about a causal relationship between specific coping mechanisms and the psychosocial variables examined are possible. In particular, it is difficult to ascertain if poor coping styles favor the development of psychological symptoms (e.g., depressive mood, phobic anxiety) or if poor social support, emotional stress, and personality variables (e.g., external locus of control, repression of anger) favor the attitude to use ineffective strategies.

A second problem concerns lack of information about several variables. Evaluation of a prior history of mood disorders, often registered among HIV-positive patients long before their infection,67,68 was not performed in this study. Likewise, data on personality disorders, which are markedly associated with both psychological vulnerability and risk of HIV infection,69–71 were not recorded. Furthermore, evaluation of other psychosocial variables, such as occurrence of stressful life events, which have been shown to increase emotional distress secondary to HIV infection,13,14,54 is also lacking in this study. Thus, the potential adverse consequences of these variables on coping, social support, and current psychological morbidity need to be addressed by future research.

Third, with regard to the sample characteristics, most of our patients were males with a history of IVDU, and this factor does not permit us to generalize the results of our study. In fact, it has been reported that persons who are IVDUs tend to have higher levels of emotional stress and depressive symptoms and fewer effective coping skills than other HIV-infected patients.72 The possible effect of current drug use, which is often denied by the patients and difficult to explore in ambulatory settings, is a further element to consider when examining the results of this study. Besides that, the difficulty in recording the mode of HIV transmission among some segments of an "at-risk" population (e.g., the possible use of intravenous drugs among homosexuals and/or the tendency to have unprotected homosexual and heterosexual intercourse among IVDUs) represents a major problem among HIV-infected patients.

Last, cultural factors should be taken into account, since it is possible that some of the variables examined, such as psychological morbidity, coping mechanisms, tendency to control emotions, and perception of support from interpersonal relations, may be different in Italian populations compared with the populations of other countries. However, data examining part of these aspects in Italian HIV-infected patients, determined by the cultural context, did not reveal significant differences in the psychosocial measures, compared with studies done in other European countries or the United States.72–76

Despite these caveats, the potential association of the FS–H construct with specific HIV-related issues, such as maintenance of at-risk and/or nonrisk behaviors, compliance with therapy, quality of life and, possibly, longer survival time warrant further investigation.


  ACKNOWLEDGMENTS

 
This study was supported by funds from the Istituto Superiore di Sanità (VII–AIDS Project) and the Ministry of University and Scientific and Technological Research, University of Ferrara. The authors thank Ron Duràn, Ph.D., for his comments on the draft version of the manuscript.


  REFERENCES

 
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 

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