Psychosomatics 41:294-300, August 2000
© 2000 The Academy of Psychosomatic Medicine
Anxiety Syndromes and Symptoms Among Men With AIDS
A Longitudinal Controlled Study
Margaret C. Sewell, Ph.D.,
Kathy J. Goggin, Ph.D.,
Judith G. Rabkin, Ph.D., M.P.H.,
Stephen J. Ferrando, M.D.,
Martin C. McElhiney, Ph.D., and
Susan Evans, Ph.D.
Received May 18, 1999; revised November 9, 1999; accepted November 18, 1999. From the Department of Psychiatry, Mount Sinai School of Medicine, New York; the Department of Psychology, University of Missouri, Kansas City, Kansas City, MO; and the Department of Psychiatry, Weill Medical College of Cornell University, New York. Address reprint requests to Dr. Sewell, Mount Sinai School of Medicine–Dept. of Psychiatry, Box 1228, New York, NY 10029.
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ABSTRACT
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This 2-year longitudinal study assessed prevalence of Axis I anxiety disorders and anxiety symptoms and their relationship to manifestations of HIV illness in a sample of nonintravenous drug users. The sample included 173 homosexual men with HIV or AIDS (HIV+/AIDS) and 84 homosexual men negative for HIV or AIDS (HIV-). Data were compared with national prevalence rates to provide a framework for interpretation. No significant differences were observed. However, compared with the general population, both HIV+/AIDS and HIV- men reported more anxiety symptoms and stress. For the HIV+/AIDS group there was a positive relationship between anxiety and HIV symptoms, fatigue, and physical limitations. No changes in rates or levels of anxiety were observed in those whose immunologic markers improved or worsened over the 2 years.
Key Words: Anxiety Disorders (General)
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INTRODUCTION
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The study of anxiety among those with serious chronic medical conditions has emerged as an important area of research and public health interest. Findings, mostly in cancer and diabetes research, suggest that anxiety may be associated with increased length of hospital stay and reduced adherence to treatment.1 In controlled studies that use the standard Structured Clinical Interview for DSM-III-R and DSM-IV (SCID) to assess at least one anxiety disorder among those with HIV illness, current anxiety disorders among HIV+ subjects ranged from 1% to 12%.2–10 However, these samples consisted predominantly of patients with asymptomatic illness, and none had AIDS at entry into the study. These results may not be generalizable to patients with advanced HIV.
Anxiety symptoms (versus full syndromal anxiety disorders) may also warrant clinical attention. In cross-sectional studies, subjects with HIV report more anxiety symptoms than the general population.2,3 Longitudinal studies have produced various results. Fell and colleagues11 found higher rates of anxiety in HIV+ men compared with HIV- men over an 11-month period. Rabkin and colleagues12 observed that over 3 years those who were HIV+ were consistently more anxious than those who were HIV- but that anxiety levels declined in both groups despite illness progression in the HIV+ group. The above studies were generally limited to asymptomatic or mildly symptomatic patients.
The current study focuses on men with symptomatic HIV illness or AIDS and an HIV- control group. The study addressed the following questions:
1. How do lifetime and current rates of anxiety disorders and current anxiety symptoms among men with HIV+/AIDS compare with an HIV- sample and general population rates?
2. What is the relationship between anxiety disorders or anxiety symptoms and measures of HIV illness such as CD4 count, viral load, physical symptoms, fatigue, and physical functioning?
3. Do anxiety disorders or anxiety symptoms change over time, and if so, are men whose immunologic markers improved or worsened over the 2 years experiencing a concomitant change in anxiety?
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METHOD
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Sample
Subjects were 267 homosexual men (112 with an AIDS-defining condition, 71 HIV+, 84 HIV-) who participated in a prospective study with semiannual assessments examining factors related to adjustment to AIDS. Eighty-four HIV- men and 69 HIV+ men who had participated in an earlier study4 at this site agreed to join our present study. The focus of new recruitment was men with AIDS, but all subjects were assessed at the same time. Initially, the 267 subjects were classified into four groups: three HIV+ groups were classified as 1) asymptomatic with a CD4 cell count >200, 2) CD4 200–499 and no AIDS diagnosis, and 3) those with an AIDS-defining condition;13 the fourth group consisted of 84 HIV- homosexual men assessed only at baseline. Flyers seeking homosexual male volunteers for a study about "coping with AIDS" were posted at HIV community-based organizations and in neighborhood bookstores that catered to homosexual men. Exclusion criteria included being too ill to come to the clinic or being a current intravenous drug user.
Procedure
Subjects were seen semiannually for assessments including psychiatric and medical interviews as well as self-reports. This study uses data from the first five study visits beginning in July 1995 through January 1998. Interviewers were fellows in an NIMH-sponsored HIV research training program. A physician in the HIV clinic (SF) supervised collection of medical information. Quest (formerly Metpath), a widely used commercial laboratory, performed the blood tests. All subjects gave written informed consent and were paid $30 per visit.
Measures
Markers of HIV Illness Stage
Laboratory. Quest laboratories performed assays to determine number and percent of CD4+ T-cells. Values under 200 cells/mm3 constitute an AIDS-defining condition according to 1993 Centers for Disease Control criteria.13 Quest also performed the HIV RNA viral load assay, using the polymerase chain-reaction technique that amplifies viral RNA. For the HIV RNA assay, the lower limit of detection was 400 copies/ml of serum. Undetectable test results were conservatively scored as 399 (2.6 log) copies.
Medical Symptoms. A checklist of 14 symptoms commonly associated with HIV infection was used. Examples include night sweats and unexplained fever. Symptoms were scored as present or not for "today." The score is the sum of symptoms present.
Fatigue. Seven self-report items of the Chalder Fatigue Scale14 assessed physical fatigue. Responses were on a Likert scale ranging from never (1) to always (5). Items include questions about feeling tired, needing rest, feeling weak, and having enough energy. Items are summed for a total score. Total scores ranged from 7 to 35.
Physical Limitations. This self-report scale,15 part of the Rand Medical Outcomes Study, includes 12 activities in descending order of difficulty such as "If you want to, can you run a short distance?" and "Can you dress yourself?". Responses are "Yes, I can do this," "Yes, but only slowly," and "No, I can't do this." Items are summed to obtain a total score, with higher scores reflecting more physical limitations.
Psychiatric Measures
Structured Clinical Interview for DSM-IV (SCID). This modular diagnostic tool for psychiatric disorders is standard in psychiatric research.16 The anxiety, depression, and substance-use modules were used as well as the psychotic screen.
Global Assessment of Recent Stress (GARS). This 8-item measure inquires about levels of stress or "pressure" within the past week in areas such as relationships, changes in life circumstances, and finances.17 By using a 9-point Likert scale, scores may range from 8–72, with higher scores reflecting greater stress.
Brief Symptom Inventory (BSI). This self-rated questionnaire provides subscale scores in nine psychological areas for the past 2 weeks.18 The Anxiety Subscale (7 items) was used to measure both physical and emotional manifestations of anxiety (restlessness, nervousness, tension) on a 5-point Likert scale. Scores may range from 0 to 28, with higher scores reflecting greater anxiety.
Spielberger State-Trait Anxiety Inventory (STAI). This 40-item questionnaire measures state and trait anxiety.19 Because of the high correlation between the trait and state scales (r=0.82, P<0.01), only the trait measure, which measures how subjects "generally" feel, was retained for further analyses. The trait scale includes 20 items, with higher scores reflecting greater anxiety.
Prevalence Comparison Rates
Rates of anxiety disorders are compared with community rates reported for a sample of nearly 20,000 adults in the multisite Epidemiologic Catchment Area study (ECA).20 The ECA used the Diagnostic Interview Schedule, which is based on DSM-III. Lay interviewers administered the Diagnostic Interview Schedule.
More recently, the National Comorbidity Study (NCS)21 used DSM-III-R diagnostic criteria on a sample of almost 10,000 adults. Although this study has the advantage of using updated criteria and we have used it here for a comparison of lifetime rates, the authors do not provide current (past month) rates; thus, ECA data will be used for these comparisons.
Statistical Analyses
We compared rates of disorders using chi-square analyses. When appropriate, we used Spearman or Pearson correlations to assess the relationship among diagnoses, continuous anxiety measures, and markers of HIV illness. Repeated measures analysis of variance (ANOVAs) assessed changes in continuous anxiety variables over time. Finally, we changed scores with repeated measures and multiple analysis of variance (MANOVAs) to assess change in anxiety over time as a function of illness. All tests were two-tailed.
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RESULTS
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Sample
Demographic characteristics
At study baseline, the sample consisted of 183 HIV+/AIDS men (112 men with AIDS, 50 men with CD4 cell counts between 200 and 500 without AIDS diagnoses, 21 HIV+ men with CD4 cell counts >500) and 84 HIV- men. An average of 89% had some college education, 32% were nonwhite, and the average age was 40. See Table 1 for a breakdown of the demographics by HIV group.
Over the 2-year period, 29 men did not complete the study (12 died, 11 dropped out, and 6 moved or were lost to follow-up). There were no significant medical or psychiatric differences between those who dropped out and those who remained (data not shown).
Medical characteristics
Table 1 illustrates medical characteristics. Nineteen of the HIV+ men were taking anxiolytics, most for insomnia. Only 4 of these 19 had a current anxiety disorder. The groups significantly differed on multiple dimensions of HIV illness progression and on physical manifestations of HIV illness such as fatigue, HIV symptoms, and physical limitations.
Prevalence
Prevalence rates of anxiety disorders across the spectrum of HIV illness
Current Anxiety Disorders. Table 2 presents the rates of current anxiety disorders (at baseline, and 1-year and 2-year time points) for both the HIV+/AIDS and HIV- groups, contrasted with community rates. Rates of disorders were too low across the three HIV+ groups to warrant statistical comparison; these groups were collapsed into one HIV+/AIDS group to facilitate comparison with the HIV- men. All further analyses were conducted on two groups: HIV+/AIDS (combined) and HIV-. For the category "Any anxiety disorder," the rates for the HIV- group (8%) were not statistically different from the rates of the HIV+/AIDS aggregate group (12%) ( 2=0.61, df=1, P=0.436). Both the HIV+/AIDS and HIV- groups had higher rates of current anxiety disorders than the ECA population (5%).
Of the 21 men with current anxiety disorders at baseline, 3 had a current mood disorder, and another 3 had both a current mood disorder and current substance or alcohol abuse disorder. In other words, 6 of 21 (28%) of the anxiety disorders were comorbid with other Axis I disorders at baseline.
Lifetime Anxiety Disorders. Table 2 presents rates of lifetime (including current) anxiety disorders for the HIV+/AIDS and HIV- groups and contrasts these data with both NCS and ECA community rates where applicable. There were no statistically significant differences between the HIV+/AIDS and HIV- groups on any individual diagnosis or the aggregate variable "Any anxiety disorder" (t=0.80, df=78, P=0.414).
Anxiety Symptoms
Mean scores for the whole sample on the anxiety measures were as follows: GARS mean was 27.08±12.79(SD), Spielberger mean was 40.15±12.12, and BSI mean was 0.623±0.70. For the group as a whole the correlation between the BSI and GARS was r=0.381 (P<0.01), between the BSI and Spielberger, it was r=0.468 (P<0.01), and between the GARS and the Spielberger, r=0.550 (P<0.01). For both the HIV+/AIDS and HIV- groups, mean scores on the BSI-anxiety were not significantly different from each other (t=1.86, df=122, P=0.066) or the population norms. However, mean baseline scores, regardless of HIV status (HIV+=27±13, HIV-=26±12), were higher on the GARS-stress than those of the community control subjects (mean=17±3).
Association Between Anxiety andManifestations of HIV Illness
There was no significant relationship between laboratory measures (either viral load or CD4 cell count) and anxiety measures at any time point (data not shown).
Relationships for the HIV+/AIDS group among anxiety (disorders and symptoms) and HIV symptoms, fatigue, and physical limitations are presented in Table 3. At each of the five occasions, anxiety diagnoses and anxiety symptoms were significantly and positively related to HIV symptoms, physical limitations, and fatigue. For the HIV- group, there were only two significant findings, which were between fatigue and the BSI-anxiety and GARS-stress scale (r=0.56 and 0.51, respectively, P<0.05). To account for the possible overlap of physical symptoms on both the anxiety and physical symptoms measures, somatic items were removed from the anxiety measures. The significant results were maintained.
Changes Over Time
Rates of anxiety disorders remained stable over the 2-year period. Scores on the BSI-anxiety and GARS-stress (the only continuous anxiety measures given at more than two time points) did not change significantly over time (GARS: F[4,119]=1.54, P=0.195; BSI: F[3, 128]=0.71, P=0.55).
By use of change in CD4 T-cell counts over time, a series of MANOVAs with repeated measures were performed to determine whether the subset of men who were getting sicker (n=53) or getting better (n=21) were also exhibiting fluctuations in the BSI-anxiety or GARS-stress. "Sicker" and "Better" were defined as an increase (getting better) or decrease (getting sicker) of at least 100 T-cells over the 2-year interval. Results were not significant (data not shown).
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DISCUSSION
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Prevalence of current and lifetime Axis I anxiety disorders did not differ between men with or without AIDS. For the HIV+/AIDS group, prevalence of lifetime anxiety disorders was not significantly elevated over the rates for the general population, although there was a trend for a higher rate of current disorders (5% population rate vs. 12% HIV+/AIDS rate), which may be related to lack of statistical power. These rates are similar to the rates reported in the HIV literature for asymptomatic HIV+ men,3,5 to the rates reported in the cancer literature,22,23 and to the rates reported in medical clinics,1 suggesting that AIDS/HIV is not associated with a specific anxiety response. These findings are of clinical importance, highlighting the fact that persistent anxiety (e.g., feeling keyed up, restless, or worried) is not a normative response to advanced HIV illness. The importance of identifying and treating those who receive care from general medical providers with comorbid anxiety disorders is underscored by Sherbourne and colleagues;24 they report a substantial difference in quality of life between those with hypertension or diabetes with or without anxiety disorders.
Interpretation of anxiety disorder prevalence and comparison with other studies is complicated by the fact that the diagnostic nomenclature and measures have changed over the past decade. For example, a diagnosis of generalized anxiety disorder in DSM-III required a duration of 1 month of symptoms, whereas 6 months of symptoms and impairment in daily functioning are required by DSM-IV. The fact that criteria for anxiety disorders are more stringent than earlier versions highlights the importance of measuring subsyndromal anxiety symptoms that may still warrant clinical attention and intervention.
In contrast to diagnostic prevalence, stress and anxiety symptoms (as measured by the GARS) for both groups were significantly higher than the general population, and these symptoms were nearly twice as high on a measure of general stress and pressure. Certain aspects of being homosexual - including stigma, anti-homosexual violence, issues around disclosure, HIV illness or the threat of illness, and watching peers die young - may contribute to stress across many aspects of daily life.
Although laboratory health markers were not related to anxiety, men with more HIV symptoms, physical limitations, and greater fatigue reported higher levels of stress and anxiety. The fact that physical manifestations of HIV are more related to distress than laboratory markers is consistent with the findings of studies with less ill populations2,11,25 as well as research on HIV and depression.26 Further, the finding that somatic complaints relate to psychological disturbance is similar to the findings of Perkins and colleagues27 in a less ill population of asymptomatic homosexual men. This finding underscores the psychological importance of managing fatigue and HIV symptoms.
The association of physical manifestations of HIV and anxiety may be understood two ways: 1) there is a bidirectional relationship between anxiety and physical distress (and what that may signify emotionally), or 2) there is an overlap between symptoms used to measure anxiety and physical symptoms themselves. Our findings were maintained even when somatic items from the anxiety scales were eliminated, suggesting that physical symptoms, limitations, or fatigue may contribute to anxiety and tension.
Concerning changes over time, neither anxiety symptoms nor disorders increased or decreased over a 2-year period. This was true for the subset of men who became more ill or, in fact, for those whose health improved. Our findings regarding the apparent stability of anxiety symptoms may be related to their assessment at 6-month intervals. When interviewed, men actually reported frequent but transient fluctuation in anxiety levels over time related to expected difficult changes (e.g., bereavement, disclosure) but also related to positive changes in their life (e.g., improving health, thoughts of returning to work). Physicians and mental health practitioners need to become attuned to anxiety related to the new optimism of a "second life" for those living with AIDS. One man noted, for example, "I never thought I'd live to 50! I never thought I'd have to deal with all these responsibilities, the mortgage, and getting older."
Several limitations of this study should be mentioned. The sample is an ethnically diverse group of homosexual men who are more ill than those often studied. Further studies should include women and intravenous drug users whose anxieties might be significantly different. Our results should be regarded cautiously because of our small cell sizes, which made subgroup comparisons difficult. Further, it would have been best to use a randomized matched sample of homosexual men as a basis of comparison, instead of general community rates, as our sample is highly self-selected. However, a complete enumeration of the homosexual community may never be available.
In summary, despite significant illness, most subjects did not have anxiety disorders or high levels of anxiety symptoms, nor did anxiety levels change significantly over time.
However, even mild levels of anxiety were associated with fatigue, physical limitations, and more HIV symptoms. Given the ever-changing landscape of HIV medical treatment, with its inherent uncertainties, clinical attention to anxiety is imperative as is continued research on the milder physical manifestations of HIV disease.
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ACKNOWLEDGMENTS
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This work was supported by National Institutes of Mental Health Grant #MH42277–11 awarded to Judith G. Rabkin, Ph.D., M.P.H. The authors thank Scott Cohen, the study coordinator, Nancy Kunz, for her statistical assistance, and Marvin Stein, M.D., for his review of this manuscript.
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ABSTRACT
INTRODUCTION
