Download Stress Response Syndrome Associated with HIV Positive Test

Stress Response Syndrome Associated with HIV Positive Test Results
In a Group of Gay and Bisexual Men
Paul D Linden
Clinical Research Project
Research to date has described individuals’
emotional response to testing positive to the
human immunodeficiency virus (HIV) as an
anxiety reaction or adjustment disorder. This
research explored the relationship between
testing positive for HIV and manifesting Posttraumatic "Stress Disorder. 115 gay and
bisexual men responded to a four-page
questionnaire that included the Impact of Event
Scale (Horowitz, Wilner, & Alvarez, 1979) and
demographic questions developed by the
researcher. Results indicated that the 74 HIV
positive subjects scored significantly higher on
the Impact of Event Scale than did the 41 HIV
negative individuals. The HIV positive subjects'
response to the items on this scale was
substantially the same as the response of other
Post traumatic Stress Disorder patients as
reported in the literature. These findings
suggested that many HIV positive individuals
experience clinical symptoms of post-traumatic
stress after being informed of a positive result to
the HIV antibody test.
Prior to exploring the emotional impact of HIV
infection, an understanding of the medical and
virological aspects of this illness is essential
(McCutchan, 1990). Lymphocytes are the basic
cell type of the immune system. B-cells
produced in the bone marrow, and stored in the
lymphoid organs remain inactive until
confronted with a health threatening pathogen
such as organic pollutants, toxins, viruses, and
bacteria. The B-cells respond to pathogens by
producing proteins called antibodies designed to
destroy the specific pathogen. T-cells respond in
a highly specific way to facilitate the action of
B-cells. Helper T-cells release chemicals called
Iymphokines that enhance the ability of B-cells
to produce antibodies. Suppressor T-cells play
the opposite role, and inhibit production of
Page 1
Illinois School
of Professional Psychology
antibodies by B-cells. Other killer T-cells
destroys antigens with lethal chemicals of their
own (Hall, 1988). The human immunodeficiency
virus (HIV) destroys helper T-cells: "Because of
the important role played by this population of
lymphocyte the infected individual is unable to
combat infectious agents that would normally be
resisted with ease" (Hall, 1988, p.90?). When
impairment of the immune system results from
the destruction of T-helper cells by HIV, the
opportunity exists for certain disease-causing
organisms to proliferate (Hall, 1988;
McCutchan, 1990).
The Centers for Disease Control established
AIDS (Acquired Immune Deficiency Syndrome)
as a classification of illness in 1981 to identify
and track a sudden unexplainable increase in the
number of individuals dying from opportunistic
infections (Morin, 1988). Opportunistic
infections are a specific group of viruses and
illnesses that individuals with normal immune
system functioning rarely contract, and that the
body generally is well-equipped to destroy
before any symptoms of these pathogens
become evident (Gallo, 1987). The opportunistic
infections that the Centers for Disease Control
consider diagnostic of AIDS include Kaposi's
Sarcoma, Pneumocystis carinii pneumonia,
Cytomegalovirus, and Herpes virus. These
viruses are common, but rarely result in illness
when the immune system is working normally
(Hall, 1988).
AIDS as a disease classification existed
before the discovery of HIV as the virus leading
to immunological dysfunction (Morin, 1988).
Not until 1992 did the Centers for Disease
Control (CDC) officially revise their criteria for
the diagnosis of AIDS to include severe
reduction of T-Helper cells. Prior to 1992, AIDS
tracking did not include individuals with HIV
infection until they developed symptoms of the
opportunistic infections considered diagnostic of
HIV Stress Response
AIDS. The human immunodeficiency virus can
affect the immune system's capacity to battle
both opportunistic and non-opportunistic
infections. Many individuals infected with HIV
have died of diseases other than those caused by
opportunistic infections without ever having met
the criteria for AI DS established by the Centers
for Disease Control (Barnes, 1987).
The Centers for Disease Control's focus on
AIDS criteria has had broad implications that
went beyond tracking and identification. Both
research funds and supportive health care
funding have often used the CDC's criteria as the
guideline for eligibility. Thus, HIV infected
individuals, who may have had serious medical
complications but who had not contracted an
opportunistic infection, frequently have found
themselves excluded from services and research
protocols (Barnes, 1987).
The CDC's focus on AIDS rather than HIV
has also had substantial emotional impact on an
individual level. HIV affected individuals have
often found themselves in a medical no- man'sIand (Triplet & Sugarman, 1987). Public
information through the Federal Government,
and community organizations, has focused
almost solely on AIDS with little attention to
HIV status (Pelosi, 1988). HIVaffected people
often have reported intense feelings of confusion
and anxiety resulting from the lack of definition
and public information regarding this condition
(Namir, Wolcott, Fawzy, & Alumbaugh, 1987).
They often have described feeling as though
they were waiting for the other shoe to drop as
they suffer through the effects of HIV while
awaiting their condition to meet the CDC's
criteria for AIDS. The recent change of AIDS
diagnostic criteria to include severe suppression
of Helper T-cells will hopefully diminish some
of these difficulties. However, there has not yet
been sufficient time to establish the actual
impact this change will have.
Transmission of the virus from an infected
person to an uninfected person requires direct
blood-to-blood contact. High rates of
transmission result from sexual activity in which
bodily fluids, high in blood cell concentration,
make contact with an uninfected person's blood
system. Transmission also occurs due to direct
injection of the virus into the uninfected person's
blood stream via blood transfusions, sharing of
Page 2
infected IV needles, and transmission of blood
across the placenta (May & Anderson, 1987).
Casual sexual contact such as hugging, touching,
and mutual masturbating has not resulted in
transmission of the virus (Goedert, 1987).
Research conducted on the human
immunodeficiency virus suggests that it is very
fragile compared to other known viruses such as
influenza, the common cold, and hepatitis.
Common household detergents such as soap,
bleach, and alcohol, as well as heat and drying,
can easily destroy HIV (COC, 1985). Research
also suggests that many enzymes in the body's
digestive system, including enzymes secreted by
the saliva glands, can destroy the virus (May &
Anderson, 1987).
Medical testing for the presence of HIV
antibodies is the method of diagnosing HIV
infection. Research has shown that it may take
as long as six months between an activity that
first exposes a person to HIV infection and these
tests' detection of HIV antibodies in the
bloodstream (Krowka, 1989). Typically, tests
can detect antibodies to the virus within the first
six to twelve weeks (Goedert, 1987).
Testing for HIV antibodies has been an area
of concern both in the medical and the
psychological literature (Buckingham, 1987;
Hawthorne & Siegel, 1987). The arguments for
testing include a belief that early detection may
improve chances for survival resulting from
early aggressive treatment of the infection
(Stimmel, 1987; Morokoff, Holmes, & Weiss,
1987). However, at the time of this writing,
medical research has been inconclusive about
whether this is true (Marks & Goldblum, 1989).
Others advocate HIV testing to induce
behavioral change (Stall, Coates, & Hoff, 1988).
Some research has shown that individuals are
less likely to engage in unsafe activity -- either
unsafe sex practices, or unsafe sharing of
needles -- because of positive HIV test results
(Coates, 1990; Marks & Goldblum, 1989;
Goedert, 1987). On the other hand, these
researchers have suggested that negative test
findings result in a reduction in precautions that
may increase chances of exposure, or even in the
spread of the infection due to false negative test
results. Additional studies have questioned the
practical significance of reported behavioral
changes subsequent to positive test results, and
HIV Stress Response
suggest that this information alone has
negligible impact (Ostrow, Kessler et aL, 1989;
Kelly & St. Lawrence, 1988).
Those against widespread HIV antibody
testing argue that the possible benefits of testing
need to be weighed against the potential harm
that testing may cause (Meyers & Dunton, 1988;
Novick, 1984; Pies, 1989; Jaffe & Wortman,
1988). They argue that because HIV infection
and the people most commonly affected are
objects of stigma, antibody test results may
subject them to discrimination. There is a
growing body of anecdotal evidence of
discrimination in housing, employment, and
insurance coverage subsequent to positive HIV
test results (Galea, Lewis, & Baker, 1988;
McCombie, 1986). Proponents against testing
also argue that the potential medical benefits of
early detection are only applicable to individuals
who have the economic resources to avail
themselves of treatments. The vast majority of
medical treatments for the early phases of HIV
infection are experimental and typically not
covered by health insurance benefits. Public
health resources already are being stretched
beyond their limits due to the HIV health crisis,
and people without substantial resources
typically do not have access to treatment during
the early phases (Weiss & Hardy, 1990). HIV
testing for these individuals may subject them to
tremendous emotional and psychological stress
with no practical benefit to offset the pain
inflicted (Marks & Goldblum, 1989). Authors
have also suggested that a person's clinical status
should be considered prior to HIV testing (Perry
et aL, 1990).
The progression of HIV illness from
infection to death varies greatly from one person
to another. Many individuals experience viral
symptoms such as nausea, low-grade fevers,
night sweats, and fatigue as an initial response to
exposure to HIV (Gallo, 1987). Yet HIV belongs
to a category of viruses called retroviruses.
These viruses have the capacity to become
incorporated into the genetic composition of the
host's cells (Hall, 1988; McCutchan, 1990).
Thus HIV has the capacity to be stored in an
inactive state within the monocyte and
macrophage cells of the host. During this
inactive state, the virus is not detectable,
although tests may detect antibodies to the virus.
Page 3
Many individuals exposed to HIV can go
symptom-free, and remain unaware of the
infection, for years.
In its active state, HIV relentlessly attacks
the Helper T- cells, resulting in a progressive
deterioration of the immune system. Patients
initially begin to experience a reduction in their
bodies' capacity to fight off common diseases
due to the loss of immune system integrity (Hall,
1988). This stage of the disease is known as
ARC (Aids Related Complex), and during this
stage, the patient is likely to experience colds,
influenza, or bacterial illnesses with increased
frequency and severity. As the immune system
becomes critically damaged, the HIV infected
individual becomes susceptible to opportunistic
infections, and finally receives the diagnosis of
AIDS (Hall, 1988).
When the immune system becomes
sufficiently suppressed to make the individual
susceptible to opportunistic infections (AIDS),
the consensus of opinion is that the illness has
reached the terminal stage (Batchelor, 1988).
Because HIV can remain in a dormant state for
many years, and because some evidence
suggests that it can move from an active state to
an inactive-dormant state leaving these
individuals symptom-free, there is considerable
difference in opinion about whether HIV
infection should be considered a terminal illness.
At the time of this writing, there is no medical
cure for HIV, and the bulk of medical evidence
suggests that HIV eventually results in severe
immune deficiency. Thus most individuals who
become aware of their infection with HIV
respond to this news as a terminal diagnosis
(Coates, Stall, Kegeles, Morin, & McKusick,
1988; McCutchan, 1990).
Emotional Impact Associated with HIV
Infection
Research suggests that there are significant
psychological difficulties associated with both
positive and negative HIV antibody test
findings. The research documents conditions of
HIV Anxiety Syndrome and issues of survivor
guilt in individuals with negative HIV test
findings (Moskowitz, 1989). The discovery that
one has an HIV infection is an emotionally
disruptive event. Due to the lethal consequences
of this infection, such a discovery often results
HIV Stress Response
in significant emotional and psychological
difficulties (Silven & Caldarola, 1989). Research
suggests several risk factors that appear to affect
a person's emotional response to diagnosis with
HIV infection. These factors include the
individual's general personality style,
community support network, severity of
environmental stress factors, previous history of
emotional stability, and current physical health
status (Macks, 1989; Morin, Charles, & Malyon,
1984).
A review of the literature suggests four
separate phases of emotional difficulties
associated with HIV infection. Each phase
represents a distinct stage of the illness with its
own associated emotional difficulties (Chuang,
Devins, Hunsley, & Gill, 1989). The first phase
begins before the discovery of HIV infection.
The second phase consists of the emotional
disruption resulting from obtaining positive HIV
test results. Phase three begins with the first
medical difficulties caused by the infection. The
fourth phase concerns issues of death and dying
when the HIV infection reaches the terminal
stage.
Several researchers have identified an HIV
Anxiety Syndrome. A phobic fear of HIV
infection is characteristic of this condition
(Krieger, 1988; Tartaglia, 1989). Other authors
have described this population as the "worried
well" (Herek & Gluntf, 1988). This group of
people typically includes individuals who have a
history of engaging in behaviors associated with
transmission of HIV who become obsessed with
the fear of exposure. This group has symptoms
of somatization and frequently pursuit of
medical reassurance regarding members' health
status. Individuals suffering from this condition
often respond with disbelief when HIV antibody
test results yield a negative finding (Jaffe &
Wortman, 1988; Bor & Miller, 1989).
Researchers also have identified a pattern of
social isolation and withdrawal from social
support systems that substantially contributes to
the debilitating escalation of the person's anxiety
symptoms (Tartaglia, 1989).
Clinical data on individuals suffering from
HIV anxiety suggested that many of these
individuals suffered from intense feelings of
guilt and self-hatred displayed in excessive
anxiety about HIV infection. Research
Page 4
conducted in San Francisco with a group of
predominantly gay and bisexual males reported
that those suffering from an HIV anxiety
disorder frequently had intense feelings of
ambivalence regarding their sexual orientation,
and displayed a predominance of internalized
homophobic beliefs. Such individuals on a
subconscious level may perceive their lifestyle
as being sinful or evil, or as deserving of
punishment. Due to the strong connection
between HIV infection and particular sexual
activities associated with the spread of this
disease, these individuals frequently reported
feeling as though they deserved the illness as
punishment for their behavior (Tartaglia, 1989).
Fundamentalist religious groups, which have
declared AIDS as God's judgment against the
sins of those who engage in high-risk behaviors,
particularly homosexual intercourse, reinforce
these self-deprecating beliefs (Geis, Fuller, &
Rush, 1986). Some researchers have
documented that within this group, there actually
can be a reduction of symptoms of anxiety
following the diagnosis of actual HIV infection
or of an AIDS related disorder (Tartaglia, 1989).
The literature has not clearly documented
the relationship between an HIV Anxiety
Syndrome and changes in risk behaviors (Martin
& Vanca, 1984). The information reported does
suggest that for many individuals, the excessive
fear of HIV infection results in a marked
withdrawal from social supports. Clinical
information shows that for some individuals, the
association between HIV and sexual activity
becomes so strong that they fear any form of
sexual intimacy regardless of the actual safety or
potential risk of the sexual activity (Shernoff,
1989). Conversely, several research articles
suggested that for some HIV-anxious
individuals, HIV anxiety may result in a
compulsion to engage in high-risk activities.
Some authors suggested that individuals at risk
due to IV drug addiction may be particularly
prone to increased risk behavior and drug usage
due to anxieties caused by fear of HIV infection
(Fisher, Jones, & Stein, 1989). It also has been
the author's experience that individuals
experiencing a low quality of life, and
propensities toward a self destructive lifestyle,
may show behaviors that appear to be in pursuit
of HIV infection despite significant anxieties
HIV Stress Response
and fears of illness.
A second emotional issue that is prominent
in individuals who test negative for the HIV
virus is a pervasive feeling of "survivor guilt"
This difficulty is most often seen in subcultures
such as gay and bisexual men living in large
metropolitan areas with high rates of HIV
infection. In some metropolitan areas such as
San Francisco, estimates of HIV infection have
ranged from fifty to as high as seventy-five
percent of the gay community. In such an
environment, an individual who tests negative
often feels isolated from the majority of the gay
community (Moskowitz, 1989). Clinical
interviews recounted from support groups for
HIV negative (HIV-) individuals revealed that
many have become so fearful that they have all
but given up sex with others. Feelings of guilt
increase as they observe friends and loved ones
die (Moskowitz, 1989). Research shows that
repetitive losses have a cumulative impact that
results in the individual's having more difficulty
resolving issues of loss following the death of
friends and loved ones (Martin, 1988; Klein &
Fletcher, 1986).
Thirdly, there is substantial research
evidence that the act of being tested for HIV
results in an acute period of anxiety. The period
between having blood drawn and obtaining the
laboratory test findings is often an extremely
difficult period emotionally (Marks &
Goldblum, 1989; Jaffe & Wortman, 1988). For
some individuals, the anticipated stress of this
period is so severe that they avoid HIV testing
altogether. Authors recommended pre-test
counseling and assistance for the individual
during this period (Magallon, 1987; Jaffe &
Wortman, 1988; Grant & Anns, 1988).
The emotional impact of obtaining HIV+
test results is one of the least researched phases
of psychological response to HIV related
disorders. This partially results from several
complicating factors that make this research
especially difficult. Individuals submit for
testing at various points in the progression of
HIV illness. While some obtain positive test
results during routine health screening, others
are tested due to the presence of symptoms that
are pathognomonic of HIV illness. Others deny
their illness and are not tested for the virus until
they are late in the progression of HIV infection
Page 5
and have opportunistic diseases. Because
research has demonstrated that the psychological
issues vary with the different phases of HIV
infection, it is difficult to differentiate the direct
impact of the positive test results from the issues
created by the progression of the illness (Chuang
et aI., 1989).
Secondly, research on asymptomatic HIV +
individuals is inherently difficult. Issues of
confidentiality of test results are significant. The
ideal setting for HIV testing is under a condition
of anonymity (Ostrow, et aI., 1989; Zonana,
1989). Thus, tracking these individuals and
obtaining concise clinical information about the
emotional impact of the positive test findings are
almost impossible.
Despite these difficulties, there is a sketchy
body of evidence from cohort studies (Joseph, et
aI., 1987; Chuang et aI., 1989; Ostrow, Monjan,
Joseph, Van Raden, et aL, 1989), and clinical
reports (Macks, 1989; Ferrara, 1984; Silven &
Caldarola, 1989) regarding the emotional
difficulties asymptomatic HIV + clients
experience. In the late '80s, research began to
report substantially higher rates of suicide and
attempted suicide in individuals who tested
positive for HIV (Frierson & Lippman, 1988;
Goldblum & Moulton, 1989). These findings
spurred a recognition of the serious emotional
difficulties experienced by these individuals.
Researchers proposed changes in the procedure
of HIV testing, with a greater emphasis on pretest and post-test intervention to identify
individuals at risk for emotional difficulties
(Jacobsen, Perry, & Hirsch, 1990).
Research data indicated that the most
commonly reported diagnoses of asymptomatic
HIV+ clients are generalized anxiety,
depression, and adjustment disorder (Atkinson,
Grant, Kenedy, Richman, et aI., 1988). However
as Nichols (1983) reported, generalized anxiety
is such a catch-all diagnostic category that it
often adds little to the understanding of the
emotional difficulties of these individuals.
Clinical information reported in the literature, as
well as this author's clinical experience,
suggested a consistent pattern in the emotional
themes reported by asymptomatic HIV +
individuals that contributes to symptoms of
anxiety.
HIV Stress Response
Statistical information revealed that most
individuals testing positive for HIV infection
were below the age of forty. Many of these
individuals reported a dramatic shift in their
anticipated life expectancy. This shift in life
expectancy often results in difficulty making
long-range plans, and patients typically restrict
life planning to no more than six months to a
year into the future (Macks, 1989; Silven &
Caldarola, 1989). Profound anxieties about
illness, and uncertainty regarding the future,
characterize asymptomatic but anxious HIV
individuals. In addition, authors have commonly
observed issues of mortality, of the existential
meaning of their life and death, as well as of
religious uncertainties (Silven & Caldarola,
1989).
Erikson theorized that specific
developmental phases characterize individual
movement through adulthood. He proposed that
adult phases of development begin with identity
formation, and then move to issues of intimacy
versus isolation. This stage is followed by issues
of generativity (productivity and procreation)
versus stagnation. The final stage of the life
cycle is integrity versus despair and disgust.
Existential issues of mortality are not
significantly represented in adult development
until the mid-life periods of generativity and
integrity (Erikson, 1982). Younger individuals
below the age of thirty-five typically view issues
of mortality as so distant from them as to be
emotionally irrelevant. Developmental research
suggested that issues of mortality only become
relevant to people as they gradually experience
the death of parents and significant others of the
generation preceding them (Jacques, 1980).
A positive HIV test result disrupts this
normal pattern of development. The threat of a
potentially lethal illness prematurely thrusts
younger individuals into a revision of their
existential view of mortality (Hackett & Cassem,
1970). Yalom has documented in his research
that any radical shift in a person's existential
views results in significant emotional pain and
disorganization of psychological functioning
(Yalom, 1980). In the author's opinion, the
intrusion and avoidance of the existential themes
of mortality distinguish the anxiety symptoms of
asymptomatic HIV + individuals from
generalized anxiety symptoms of other clients.
Page 6
Research by Horowitz with individuals who
have experienced catastrophic life events
indicated that a central component to a post
traumatic stress response is a temporary
disruption in the individual's existential views of
mortality and safety (Horowitz, 1986). This
commonality in clinical themes underlying the
overt symptoms of anxiety has led this author to
propose that a diagnosis of post-traumatic stress
response may be more clinically accurate for
asymptomatic HIV + individuals than
generalized anxiety, adjustment disorder, or
depression. Research findings consistently have
reported that the experience of the initial
medical complications caused by HIV infection
was the most psychologically stressful period for
HIV infected individuals (Atkinson et aL, 1988;
Dilley, Ochitill, Peri, & Volberding, 1985).
Several authors have demonstrated that the
emotional response to medical difficulties
caused by HIV was not unlike the emotional
pain experienced by cancer patients during the
fifties and sixties, when treatment strategies
were less well developed (Dilley et at, 1985).
The initial experience of illness subjects HIV
infected individuals to medical procedures that
are often highly technical and confusing.
Although the development of treatments such as
AZT, 001, Interferon, and prophylactic
treatment against Pneumocystis has diminished
the hopelessness of HIV infection, these
treatments continue to stir controversy with
often contradictory reports of clinical
effectiveness. HIV individuals often lack
sufficient information to make important
decisions regarding what treatments to pursue or
reject. Significant side effects and toxicity often
reported with these treatments further
complicate this issue. During the initial phases
of illness, HIV infected individuals often
experience a decline in function rather than a
relief of symptoms following the beginning of
treatment (Woods, 1989; James, 1989).
Denial of the life-threatening potential of
HIV infection has been well documented as a
frequent and often adaptive psychological
response to being HIV+ (Buhrich, 1986; Grant
& Anns, 1988; Krieger, 1988). The beginning of
medical treatment for HIV infection
significantly disrupts individuals' capacity to
maintain their repression and denial of the
HIV Stress Response
emotional issues associated with the illness. This
is further complicated by the pharmacokinetics
of AZT requiring a rather precise maintenance
of therapeutic dosage. Patients on this
medication often need to maintain a precise
regimen of taking this drug during both daytime
and sleeping hours. Being awakened in the night
to take medications, or using alarms during the
day as a reminder often results in a relentless
reminder of their condition that floods them with
emotions associated with this fact (Sheridan &
Sheridan, 1988; Isaacs, 1985).
A good deal of correlational data has
suggested changes in lifestyle such as stress
reduction, improved diet, regular exercise,
elimination of smoking, and reduced substance
usage associated with improved functioning and
longer survival (Cecchi, 1984; Kiecolt-Glaser &
Glaser, 1988; Kiecolt-Glaser & Glaser, 1987;
Livingston, 1988). However, research on weight
loss and smoking cessation has clearly
documented that making these types of life
changes can be extremely stressful. For HIV
infected individuals, difficulties realizing these
"healthy living" objectives often can result in
intense self-reproach and guilt (Livingston,
1988). Several research studies have suggested
that due to the life threatening potential of HIV
illness, health-care providers often responded to
patients in an overly critical fashion when they
demonstrated difficulties in making prescribed
life-style changes (Grant, 1988; Hays & Lyles,
1986).
The use of recreational drugs and alcohol is
of special concern in reference to HIV infection.
Research has associated the use of these
substances with decreased immune system
functioning and clearly contra-indicated them
for HIV infected individuals. However, research
also has documented that individuals who
abused substances had an overreliance on
avoidance, repression, and denial as defenses
against stress and emotional difficulties (Fisher
et aI., 1989). Many substance abusers become
trapped in their addictions due to the capacity of
these substances to bolster effective use of
repression and denial. Abstinence from these
substances can thus result in a substantial
disruption in the individuals' normal defense
mechanisms leading to severe emotional stress
and mental disorganization. HIV infected
Page 7
individuals with a history of substance abuse
often find themselves trapped between a positive
striving for life and a nihilistic retreat into eat,
drink, and be merry for tomorrow we shall die
(Faltz, 1989).
The intrusion of medical difficulties caused
by HIV illness also can result in significant
social and environmental stressors. The presence
of illness often results in a demand to inform
family and friends of HIV + status. Research has
clearly documented a frequent pattern of
rejection and discrimination due to general
ignorance and fear of the illness (Hays & Lyles,
1986). Disclosure of substance addiction or of
alternate sexual orientation often causes social
stigmatization (Chuang et aI., 1989; Christ,
Wiener & Moynihan, 1986; Bor, Miller & Perry,
1989). Thus, individuals often experience a
depletion of social supports at a time when they
most need these resources. Significant illness
often results in decreased capacity to function at
work, which adds severe financial stress. The
high costs of medical treatment for HIV illness
further strain the individuals' resources. Poverty
or bankruptcy is a common result of these
environmental pressures (Christ et aI., 1986).
Research has shown that when individuals
entered the terminal stage of HIV illness,
anxiety and emotional tension often decreased.
Researchers have speculated that the severity of
illness may result in a process of resignation that
reduces emotional tension (Saer, 1989). Others
have speculated that due to the physical taxation
of severe illness, terminal patients often take a
more passive role and allow medical procedure
to dominate them, relinquishing their autonomy
(Namir et aI., 1987; Chuang et aI., 1989).
However, many authors have documented that
terminally ill patients often needed professional
support. A body of evidence has reported severe
psychological difficulties associated with AIDS
(Bae, 1989).
Research has documented that there can be
severe neuropsychological deficits resulting
from HIV infection of the central nervous
system (Van Grop, Miller, Satz, & Visscher,
1989). Additional complications caused by
opportunistic infections of the central nervous
system also result in AIDS related dementia
(Dilley & Boccellari, 1989). Research has
documented that these conditions can result in
HIV Stress Response
serious difficulties for individuals in the later
stages of HIV illness. Some researchers have
proposed that as many as two thirds of AIDS
patients demonstrate some symptoms of
neurological deterioration (Van Grop et aI.,
1989). These cognitive deficits often result in
severe functional limitations and loss of coping
resources that require special treatment
intervention and psychological supports
(Boccellari & Dilley, 1989).
Many researchers have noted a resurgence
of suicidal ideation in patients as they entered
the terminal stages of HIV illness (Frierson &
Lippman, 1988). These suicidal feelings have
posed a unique issue for some therapists in
coping with what has been described as “rational
suicide.” As the quality of life for AIDS
patients deteriorates, there may come a point at
which recovery seems hopeless. Some authors
have argued that active efforts to diminish the
suffering associated with terminal decline via
suicide may be sufficiently reasonable to be
considered rational behavior and not evidence of
psychiatric disorder (Goldblum & Moulton,
1989). The Hemlock Society in fact makes
information regarding effective methods to
commit suicide available to terminally ill AIDS
patients due to its belief that suicide during
terminal illness is justified and rational
(Goldblum & Moulton, 1989).
Research has shown that many terminally ill
AIDS patients had significant need for
assistance in preparing for death and settling
their affairs. There was often a desire to settle
old conflicts and resolve relationships as a part
of the terminal process (Nichols, 1983).
Research also suggested that existential themes
and religious concerns often reappeared during
the terminal phases (Dilley et at, 1985).
Post-traumatic Stress Disorder
Psychologists have long recognized that
traumatic life events can result in significant
emotional difficulties resulting from the extreme
stress these traumatic events cause. Research has
indicated that intrusive ideas, ideational denial,
and emotional numbing are the hallmark
symptoms that characterize a stress response
syndrome (Horowitz, Wilner, Kaltreider, &
Alvarez, 1980). The Diagnostic and Statistical
Manual of Mental Disorders (DSM III-A)
Page 8
defined Post-traumatic Stress Disorder (PTSD)
in terms of specific symptoms that exist in
conjunction with a history of traumatic stress
(American Psychiatric Association, 1987).
These symptoms include the following:
recurrent and intrusive distressing recollections
of the event, recurrent distressing dreams of the
event, suddenly acting or feeling as if the
traumatic event were recurring, and intense
psychological distress at exposure to events that
symbolize or resemble an aspect of the traumatic
event. Secondarily, the patient avoids the stimuli
associated with the event by avoiding thoughts
or feelings associated with the event, avoiding
activities associated with the event, showing an
inability to recall aspects of the event, displaying
diminished interest in significant activities,
feeling detached or estranged from others,
exhibiting a restricted range of affect, and
having a sense of a foreshortened future.
Thirdly, the patient reports symptoms of
increased arousal manifest in difficulty falling
asleep, irritability or outbursts, difficulty
concentrating, hypervigilance, exaggerated
startle response, or physiological reactivity when
exposed to events that symbolize or resemble an
aspect of the traumatic event. Finally, these
symptoms last for longer than a month following
the traumatic event. However, several
researchers have suggested that the current
diagnostic criteria do not include many of the
symptoms often observed following a traumatic
event. Research has found additional symptoms
of rage, symptoms of somatization, increased
substance abuse, and feelings of guilt over
survival or actions during severely stressful
periods (Kuhne, Baraga, & Czekala, 1988).
The initial conceptualization of PostTraumatic Stress Disorder in the DSM III made
a distinction between delayed and undelayed
onset. Research has indicated no significant
differences in the symptoms associated with
delayed or undelayed onset of the disorder. This
research concluded that the difference between
the two is minor and might not justify their
being identified as separate disorders (Watson ,
Kucala, Manifold, Vassar, & Juba, 1988).
Subsequently, the authors down played this
distinction in the DSM III-R and placed delayed
and undelayed onset as two subtypes of the same
disorder.
HIV Stress Response
Besides some disagreement over the
symptoms that are pathognomonic of a Posttraumatic Stress Disorder, there is also
substantial disagreement regarding the excessive
emphasis of the DSM criteria upon specific
etiology. PTSD is the only mental disorder in
which etiology is the primary defining feature.
Both the DSM and DSM II defined the
forerunners of PTSD as a reaction to extreme
and unusual stress. In the DSM-III, there was a
shift from the environmental event to its impact
on the individual. However, the criteria continue
to demand that the event is outside of normal
human experience and would evoke significant
symptoms of distress in almost anyone (Brett,
Spitzer, & Williams, 1988). Horowitz argued
that many individuals experience symptoms
associated with PTSD as a response to events
that are not outside the range of human
experience but are shocking and uncommon
experiences for the individual who undergoes
them for the first time. He further stated that
when an external event precipitates intrusive
thinking as well as other cardinal symptoms of
post-traumatic stress, this diagnosis is more
appropriate than that of an Adjustment Disorder,
which is less symptomatically specific
(Horowitz, 1986).
Research dating back to Breuer and Freud's
(1954) earliest investigations into hysteria
indicated that intrusive thoughts and avoidance
behavior are the hallmark symptoms associated
with traumatic experiences. Psychologists have
theorized that traumatic events expose
individuals to situations that contradict or
confront their way of understanding and making
sense of the world. As such, the traumatic event
is substantially outside their normal experiences.
Psychologists have thus suspected that
individuals who have experienced a traumatic
event frequently rehearse this event via
recollections and intrusive thoughts in a
subconscious effort to master this experiential
anomaly (Horowitz, 1975). In a series of
research studies, Horowitz (1975, p. 1457) found
that a "tendency toward intrusive and stimulusrepetitive thought is not restricted to 'traumas' or
a few predisposed individuals. Intrusive and
repetitive thought appears to be a general stressresponse tendency seen in a large proportion of
persons after even mild to moderately stressful
Page 9
events." Secondly, because traumatic events are
significantly beyond normal experience and
contradict people's ways of understanding their
environment, recollections are emotionally
distressing events. Thus, people employ
symptoms of avoidance and emotional numbing
as defensive mechanisms to prevent them from
being emotionally overwhelmed by the intrusive
recollections.
Given this understanding, clinical research
has speculated that intrusive symptoms have an
important role in maintaining avoidance
symptoms. However, some research evidence
has indicated that with treatment, and over time,
intrusive symptoms tend to diminish whereas
avoidance symptoms do not. These findings
suggested that meaningful factors other than
intrusion symptoms contribute to the
maintenance and perhaps even to the initiation
of PTSD avoidance behavior (Burstein, 1989;
Keane, 1989).
Some research also has indicated that sleep
disturbance may be the most significant
component of a Post-traumatic Stress Disorder.
These findings suggested that the dream
disturbance associated with PTSD may be
relatively specific for this disorder and that
dysfunctional REM sleep mechanisms may be
involved in the pathogenesis of the post
traumatic anxiety dreams. Results also indicated
that REM sleep may participate in the control of
the classical startle response described in PTSD
patients (Ross, Ball, Sullivan, & Caroff, 1989).
Clinical studies have indicated a consistent
and universal pattern of themes in ideational
content following a traumatic experience. These
themes include a fear that the event will recur, a
fear of merger with the victims, shame and rage
over vulnerability, rage at the source of the
trauma, rage at those exempted from the
traumatic experience, fear of loss of control of
aggressive impulses, guilt or shame over
aggressive impulses, guilt or shame over
surviving, and sadness over losses (Horowitz,
1986).
A review of the literature indicated that
there are currently several Post traumatic Stress
Disorder measuring instruments. A study of 161
World War W II and Korean Conflict prisoners
of war found significant differences between the
121 individuals diagnosed as having PTSD and
HIV Stress Response
their 40 nondiagnosed counterparts on the Beck
State-Trait Anxiety Inventory (STAI), the
MMPI scales Sc, and F, and the PTSD scale
developed by Keane, Malloy, & Fairbanks
(1984) (Sutker, Bugg, & Allain, 1991 ).
Charles Watson (1990) conducted a review
of the psychometric literature on 12 PTSD
measures. He found that these measures fell into
three categories. The first set of instruments
composed of structured interviews included
Robins and Helzer's (1985) Diagnostic Interview
Schedule (DIS); Spitzer and Williams' (1986)
Structured Clinical Interview for DSM-III
(SCID); Davidson, Smith, and Kudler's (1989)
Structured Interview for PTSD (SI-PTSD); and
Watson, Juba, Maifold, Kucala, and Anderson's
(1988) PTSD Interview. The second group was
inventory scales: Keane, Malloy, and Fairbanks'
(1984) Minnesota Multiphasic Personality
Inventory (MMPI) PTSD subscale; Keane,
Caddell, and Taylor's (1988) Mississippi Scale
for Combat-Related PTSD; and the PTSD
section of Wilson and Krauss' (1984) Vietnam
Era Stress Inventory (VESI). The third group
consisted of partially structured interviews and
questionnaires: Goldstein, van Kammen, Shelly,
Miller, and van Kammen's (1987) PTSD
interview; Solomon, Benbenisti, and
Mikulincer's (1987) PTSD Questionnaire; and
combined inventory and self-rating methods
developed by Card (1983), by Foy, Sipprelle,
Barret-Rueger and Carroll (1984), and by Hyer,
O'Leary, Saucer, Blount, Harrison and
Boudewyns (1986). Watson's review of the
psychometric properties indicated that literature
seems to recommend the Mississippi Scale of
Combat-Related PTSD (Keane et at, 1988), the
Spitzer and William's (1986) Structured Clinical
Interview for DSM-III PTSD module, and the
PTSD Interview (Watson et aL, 1988). Although
this review did not include the Impact of Event
Scale (IES) (Horowitz, Wilner, & Alvarez,
1979) used in this study, it did include the scale
developed by Hyer et al. (1986) that combined
trauma history, startle and guilt self-ratings, and
scores on the lEBo Watson found that the Hyer
et al. instrument lacked reliability studies, and
had no published correlational studies with other
PTSD measures. However, several research
studies have demonstrated the validity and
reliability of the Impact of Event Scale (Zilberg,
Page 10
Weiss, & Horowitz, 1982; Schwarzwald et aI.,
1987; Woolfook & Grady, 1988).
A computer search of the literature
published between 1981 and 1991 indicated that
there were 555 PTSD research articles published
on combat- and veteran- related PTSD and only
446 studies published on non-combat-related
PTSD. Although the majority of research has
associated PTSD with combat-related stress, the
research also documented PTSD symptoms as a
response to many other severely stressful events.
Research has documented symptoms of Posttraumatic Stress Disorder as a reaction to
concentration camp detention (Eaton, Sigal, &
Weinfield, 1982; Nadler & Ben-Shushan, 1989),
nuclear holocaust (Lifton, 1967), natural
disasters (Green, 1982), bereavement (Raphael,
1983), rape (Burgess & Holmstrom, 1974),
sexual abuse (Patten, Gatz, Jones, & Thomas,
1989), urban violence (Breslau, Davis, Andreski,
& Peterson, 1991; Pynoos, & Nader, 1988), and
medical illnesses (Kaltreider, Wallace &
Horowitz, 1979).
In a study of 1,447 men advised of their risk
for coronary heart disease, the researchers found
that disclosure of this information was a
distressing event and that a small group of men
experienced distressing intrusive thoughts for as
long as three years after learning of the
information disclosed (Horowitz, Simon,
Holden, Connett, Billings, Borhani, & Benfari,
1983). This research was important in that it
demonstrated that knowledge of medical risk
could be a traumatic event. This study led this
author to suspect that asymptomatic HIV +
individuals might respond to the knowledge that
they had been exposed to a life threatening
illness as a traumatic event that could result in a
Post traumatic Stress Disorder.
A review of the literature indicated that
there have been only two studies that have
associated symptoms of a Post-traumatic Stress
Disorder and AIDS or HIV infection. Geller
(1989) presented a case report of a 42-year-old
institutional staff worker who developed severe
symptoms of post-traumatic stress after being
bitten by a HIV+ inmate. A study of 43 mothers
who had sons who died of AIDS found that two
to three years after the death of their sons, the
mothers who had devoted themselves to fulltime care of their sons for a substantial period of
HIV Stress Response
time demonstrated a cluster of symptoms similar
to a Post-traumatic Stress Disorder (Trice,
1988). Although the Post-traumatic Stress
Disorder literature associated unexpected illness
or diagnosis with a potentially life-threatening
condition with symptoms of post-traumatic
stress, the connection between PTSD and HIV
diagnosis remains unexplored in the scientific
literature.
METHOD
Subjects
The researcher initially attempted to recruit
participants from various AIDS medical services
and support programs throughout the Chicago
metropolitan area. He contacted either by letter,
phone, or in person fourteen programs listed in
the TPAN Aware Journal as providing support
services to HIV affected individuals. Three of
the fourteen services programs agreed to
participate in the study. Two of the three
programs were self-help HIV support programs.
The third was a private group psychotherapy
practice. Due to the small number of HIV
support programs that agreed to participate in
the study, the researcher choose to limit the
scope of the study to gay and bisexual men. He
then recruited additional subjects from various
informal social organizations servicing the gay
and bisexual community. Although he
distributed the research instruments to various
service programs for homosexual and/or
bisexual men, there was no way to ensure a
representative selection, and thus this study
cannot claim to be an accurate sampling of the
population. Approximately 1,000 research
instruments were distributed to the various
organizations that agreed to participate in the
study. A total of 115 subjects responded. 74
subjects indicated that they had tested positive
for the HIV virus. 41 of the subjects indicated
that they had tested negative for the HIV virus.
Each participant was given a four-page
questionnaire to complete containing Horowitz'
Impact of Event Scale (Horowitz, Wilner, &
Alvarez, 1979) and demographic questions
developed by the researcher (See Appendix A).
Participants picked up the research instrument
voluntarily from the various points of
distribution, and returned the completed
questionnaires to the examiner by mail. The
Page 11
questionnaire was post-paid and addressed to a
mail box rented exclusively for the use of this
study.
Instrument
The researcher selected Horowitz' Impact of
Event Scale (IES) due to its brevity and proven
reliability. This instrument has fifteen items that
measure two factors-- intrusion of painful
recollection (IESI), and avoidance (IESA)-clinically associated with a stress response
disorder (see Table 1). Original validity studies
suggested that the instrument is a sensitive
measure of the clinical manifestations of posttraumatic stress. Results from the initial research
with the IES reported mean scores for the
clinical population of 21.0 for both men and
women on the Intrusion Subscale. On the
Avoidance Subscale, men in the clinical
population obtained a mean score of 35.3, and
women had a mean score of 42.1. Statistical
analysis revealed significant levels of
discrimination when compared to a non-clinical
control group of college students. Men in the
control group scored a mean of 2.5 on the
Intrusion Subscale, and women had a mean
score of 6.1. The mean score for men in the
control group on the Avoidance Subscale was
6.9, and women had a mean score of 12.7. The
differences in scores obtained reached levels of
significance measures at (F=212.1, p< .0001) for
Intrusion, (F=73.0 p<.0001) for Avoidance, and
(F=170.8, p<.0001) for the total stress score
(Horowitz et aI., 1979). A cross-validation study
indicated equally high levels of significance for
item sensitivity, reliability, and capacity to
measure changes in levels of stress following
treatment (Zilberg, Weiss, & Horowitz, 1982).
The demographic questions developed by the
researcher inquired into five areas including
general demographics, health status, emotional
status, social support network, and social impact
of HIV + results. The researcher selected these
categories to reflect the factors cited in research
that increase the level of stress experienced due
to HIV infection (Macks, 1989; Morin et aI.,
1984).
The research instrument also contained an
introductory letter to provide information
regarding the reason for the research and how it
would use the results. Due to the ethical issues
HIV Stress Response
involved regarding research with HIV +
individuals, the instrument was completed
anonymously and no signed consent was
obtained (Bayer, Levine, & Murray, 1984;
Committee for Protection of Human Participants
in Research, 1986; Melton & Gary, 1988;
Novick, 1984; Zonana, 1989). The researcher
worded the letter to provide as much information
as feasible to ensure compliance with the ethical
requirement of informed consent of research
participants (Committee for Protection of
Human Participants in Research, 1986).
RESULTS
Relevance of Impact of Event Scale
Subjects endorsed all items on the Impact of
Event Scale (IES) (Horowitz, Wilner, &
Alvarez, 1979) frequently with a range of 58%
to 92% in the HIV + group, suggesting a high
level of relevance of the item pool for this
instrument. Separate endorsement data for the
HIV + and HIV groups (as well as mean item
scores) appear in Table 2. Comparison of the
rank order of items based on frequency of
endorsement in the HIV + group with the rank
order reported previously by Horowitz et. al.
(1979) for the mixed-event male patient groups
obtained a Spearman rank correlation (rs) of .75
(p<.002). The HIV- group obtained a Spearman
rank correlation (rs) of .58 (p< .05). The rank
order of items based on frequency of
endorsement in the HIV + group, when
compared with the rank order of endorsement
reported previously by Zilberg, Weiss and
Horowitz (1982) for a patient bereavement
group, yielded a Spearman rank order
correlation (rs)) of .80 (p<.002), and the HIVgroup yielded a Spearman rank order correlation
(rs) of .66 (p<.01). When compared with the
rank order of endorsement Zilberg et al. (1982)
reported for the field subject bereavement group,
the HIV+ group yielded a Spearman rank order
correlation (rs) of .64 (p<.01), and the HIVgroup yielded a correlation (rs) of .45 (N.S.).
Both the HIV+ group (rs) .34 and the HIV group
(rs) .15 showed no significant correlation with a
group of 75 male medical students who
completed the IES after dissecting a cadaver
(Horowitz et aI., 1979).
These results suggested that the content of
Page 12
experiences following traumatic events as
represented in the IES item pool is similar across
types of events and patient populations. These
findings also suggested that taking an HIV test is
a traumatic event, and the HIV + group
consistently showed a higher level of correlation
with PTSD groups than did those who were
HIV-. Table 2 also shows that HIV+ individuals
scored significantly higher than did HIVindividuals on all of the IES test items with the
exception of items 3, 7, 9, and 13. All four of
these items were on the Avoidance Subscale
(IESA). However, between-group t tests were
significant for both the Avoidance (IESA) and
Intrusion (IESI) Subscales at the p<001 level.
Likelihood Ratio Chi-Square tests conducted
for the HIV+ and HIV groups obtained no
significant between-group differences on the
general demographic variables (see Table 3)
with the exception of differences in employment
status (p<.001) that indicated that more HIV+
individuals were unemployed or on disability.
The two groups also consequently varied on
annual income (p<.01), and HIV+ subjects more
frequently reported less income. Between-group
variance for employment was nonsignificant for
the IES total score (lEST) (F=1.07, df=4), IES
Intrusion Sub-scale (IESI) (F=1.84, df=4), and
IES Avoidance Subscale (IESA) (F=1.37, df=4).
Between-group variance for annual income was
also not significant for (lEST) (F=1.12, df=4),
for (IESI) (F=1.46, df=4), and for (lESA)
(F=0.86, df=4).
Health Status
Data did not confirm the hypotheses that
HIV + individuals experiencing more severe
medical difficulties would score higher on the
IES. Between-group tests of variance indicated
no significant differences in the lEST scores on
the Health Status demographic variables. (See
Table 4) The author conducted a multivariate
analysis of variance for Current Diagnostic
Status and Current Health Status. The combined
effect of these variables yielded an F=2.56, df=2
for lEST scores, which was not significant.
Results indicated that HIV + individuals who
reported being asymptomatic scored
significantly higher on the IESA Subscale (see
Table 4). A multivariate analysis of variance
F=7.17, df=2 (p<.001) also confirmed these
HIV Stress Response
findings.
Emotional Status
Data confirmed the hypothesis that
individuals who were currently experiencing
more general emotional distress would score
higher on the IES for both lEST and IESI. A
rank order multivariate analysis of variance
performed on the combined effect of individuals'
report of current emotional status and their use
of psychotropic medications indicated a
significant covariance of these items and scores
on the lEST F=3.79, df=2 (p<.05) and IESI
F=5.72, df=2 (p<.01). The amount of covariance
of these items on IESA F=1.37, df=2, was not
significant.
Social Resources and Social Support
Data confirmed the hypothesis that
individuals who had fewer social resources and
more limitations in their access to social support
would score higher on the IES. A ranked order
multivariate analysis indicated significant
covariance on lEST F=2.56, df=7 (p<.05) and
IESA F=3.92, df=7, (p<.001) for the combined
effect of informing others of their HIV status
and the number of resources from which
subjects stated that they were receiving
emotional support. Between-group differences
for the individual variables showed that
individuals who had informed their employer of
their HIV status scored significantly lower on
IESA than did individuals who had not F=8.00,
df=2 (p<.001). The between-group differences
for individuals in group psychotherapy and other
formal support programs were inconclusive
because the number of subjects in both of these
conditions was extremely low (N=4). This made
the statistical findings unreliable.
HIV Impact on Social Network
Data did not confirm the hypothesis that
individuals would score higher on the IES if
they had lost friends or romantic partners to
AIDS. A multivariate analysis for ranked order
data on the combined variance associated with
these variables indicated no significant
covariance on the three IES scores (for lEST,
F=1.67 df=4; for IESI, F=1.00, df=4; for IESA,
F=2.16, df=4). These variables included the
number of friends reported to be HIV +, the
Page 13
number of friends who had died from AIDS, the
number of romantic partners who had died from
AIDS, and whether the subject was involved in
the relationship when the romantic partner died.
Between-group tests for the individual variables
indicated that HIV + individuals involved in a
relationship when the romantic partner died
from AIDS endorsed significantly fewer
Avoidance items (see Table 5).
Social Losses Due to HIV Status
Data partially confirmed the hypotheses that
people who had experienced social prejudice
against HIV infection would score higher on the
IES. A multivariate analysis that combined the
effect of the loss of employment, loss of
insurance coverage, loss of friendships, and loss
of romantic relationships due to discovery of
HIV status associated these experiences with
higher IESI scores, F=2.40, df=4 (p<.05). It
found no significant covariance for these
variables and lEST, F=1.64, df=4 or IESA,
F=1.79, df=4. A between-group test of variance
significantly related loss of friendships to
increased IESI scores (see Table 6).
DISCUSSION
Results from this study indicated evidence
that individuals respond to testing positive for
the human immunodeficiency virus as a discrete
traumatic stress event. In this study, HIV +
individuals' endorsement of items on the IES
indicative of a Post-traumatic Stress Disorder
significantly correlated to the frequency of items
endorsed by other patients diagnosed with this
condition. A review of the clinical literature
suggested that there has been little exploration of
post-traumatic stress symptoms in this
population. It is the author's perspective that the
diagnostic profiles most frequently reported in
the literature, such as generalized anxiety,
depression, and adjustment disorder (Atkinson,
Grant, Kenedy, Richman et aI., 1988), may
minimize the emotional distress experienced by
HIV + individuals. Results from this study
suggested that clinicians need to be sensitive to
the possibility that their HIV + patients may be
experiencing symptoms of post-traumatic stress.
Data gathered in this research project also
indicated that life events may affect the intrusion
HIV Stress Response
and avoidance symptoms of post-traumatic
stress differently. Results suggested that
asymptomatic individuals endorsed more
avoidance symptoms than did individuals who
had mild to severe medical problems. Denial of
the life-threatening potential of HIV infection
has been well-documented as a frequent and
often adaptive psychological response to testing
HIV + (Buhrich, 1986; Grant & Anns, 1988;
Krieger, 1988). These research results also
supported the observation that the beginning of
medical treatment for HIV infection
significantly disrupts individuals' capacity to
maintain repression and denial regarding the
emotional issues associated with the illness.
The presence of illness often results in a
pressure to inform family and friends of their
HIV + status. Results from this study suggested
that the more open a person was in regards to
this HIV status, the fewer avoidance symptoms
he endorsed on the Impact of Event Scale. It was
particularly interesting to discover the very
strong between-group difference observed
between people who had informed their
employer of their HIV status and those who had
not. Employment is often one of the areas in
which people tend to be the most guarded due to
the potential threat of lost income. Informing an
employer of one's HIV status may be a
significant delineator in the degree of denial and
avoidance.
Research has clearly documented a frequent
pattern of rejection and discrimination due to
general ignorance and fear of the illness (Hays
& Lyles, 1986). This study indicated that only a
small number of participants had experienced
overt discrimination as a result of their HIV
illness. However, 20% or more of the subjects
reported the loss of friendships or romantic
relationships as a result of their positive HIV
status. Research results also indicated that
individuals who had suffered this type of
personal rejection scored higher on the Impact of
Event Scale Intrusion items.
Although this study was exploratory in
scope, the findings provided substantial
evidence that warrants further research. This
study used an informal method to gather
subjects, and therefore did not insure against
selection bias. Subjects were self-selected for
this study based on a mass distribution of the
Page 14
research questionnaire. It is possible that people
who responded to the questionnaire did so
because they found the items on the instrument
particularly representative of their experiences,
whereas those who did not may have
experienced the items as more irrelevant. Results
indicated that the HIV- subjects scores higher on
the IES scale then might have been expected,
which may have resulted from a self-selection
bais.
Secondly, many of the HIV + individuals
were recruited from HIV + self help support
networks, and 58 percent of the HIV + subjects
reported that they attended a HIV support group.
Individuals who have sought out emotional
support via such services may be substantially
different from HIV positive individuals who
have not sought out such support resources.
Although the results from this study did not
indicate any significant differences on the IES
between the HIV + subjects who attended HIV +
support groups and those who did not, research
has suggested that people who isolate
themselves after learning of their HIV +
diagnosis often suffer more severe emotional
difficulties (Grant & Anns 1988). Results from
this study also suggested individuals who were
more open about their HIV + status obtained
significantly lower scores on the IESA.
Additionally, this study limited subjects to
gay and bisexual men. Although the experience
of traumatic stress as a reaction to testing HIV+
is likely to occur across populations, additional
research must confirm or negate such a
hypothesis.
This research study also demonstrated some
of the significant difficulties identifying and
conducting research with HIV + individuals.
The greatest challenge for this study was
distributing the questionnaire to individuals for
whom it was appropriate. Unfortunately, this
researcher found that organized social services
agencies were hesitant to assist in independent
research projects. Several agency directors
informed this researcher that they restricted their
research participation to studies that offered
financial backing from large universities or
governmental institutions. A replication of this
study with a larger sample and more diverse
population would likely require substantial
funding, and formal institutional sponsorship.
HIV Stress Response
In addition to increasing the sensitivity of
therapists to the possibility that their HIV+
patients may experience symptoms of PTSD,
accurate diagnosis can significantly contribute to
treatment. As Nichols (1983) reported, the
catch-all diagnostic category of Generalized
Anxiety often adds little to the understanding of
the emotional difficulties of these individuals.
Although the difference between Generalized
Anxiety symptoms and PTSD symptoms may be
subtle, a sensitivity to the presence of posttraumatic symptoms may add substantially to the
understanding of the patient. Research by
Horowitz on individuals who have experienced
catastrophic life events indicated that a central
component to a post-traumatic stress response is
a temporary disruption in the individual's
existential views of mortality and safety
(Horowitz, 1986). The recognition of an HIV+
individual's perception of imminent life
endangerment can significantly aid the
therapist's capacity to empathize with his or her
HIV + clients.
Literature has also documented treatment
strategies and interventions that are specific for
the treatment of PTSD: “Completing integration
of an event's meanings and developing
adaptational responses are the goals of treating a
stress response syndrome" (Horowitz, 1986, p.
123). Although both brief and long-term
psychotherapy approaches have been utilized in
the treatment of PTSD conditions, the focus of
treatment remains the integration of the
traumatic event. Research has documented
consistent and predictable phases of a patient's
recovery during treatment for PTSD. An initial
phase experienced by many patients after a
trauma consists of acute denial with intense
numbing or an inability to recall the event.
Research suggests that this precedes a period of
decreased controls and intense intrusion
symptoms. PTSD patients then typically
experience a period of intolerable swings
between intrusion symptoms and paralyzing
denial and numbness. This intolerable swing
between intrusion and denial then often gives
way to a period of rigid overcontrol with few
intrusion symptoms. Research has indicated that
as people gradually begin to incorporate the
traumatic event, they begin to be able to tolerate
episodes of ideation and waves of emotion about
Page 15
the traumatic event. Finally, towards the end of
treatment, patients are able to work consciously
on feelings and thoughts associated with the
trauma (Horowitz, 1986).
Accurate diagnosis of PTSD symptoms in
HIV + individuals can significantly aid the
therapist in treatment by bringing a substantial
body of treatment research to bear. As an
example, an understanding of the typical phases
of a patient's response to a traumatic event can
aid the therapist in selecting treatment goals that
appropriately bolster faltering psychological
defenses during the initial phases, or decrease
the patient's avoidance during the later stages of
treatment. Application of appropriate diagnosis
and treatment approaches can also aid the
therapist in monitoring progress as the therapist
observes a patient's move through the phases
typically seen in treatment for PTSD.
This research also added to a body of recent
work that has suggested that the application of
PTSD as a diagnostic category needs
broadening. PTSD is the only mental disorder in
which etiology is a primary defining feature.
The DSM III-R criteria require that the event is
outside of normal human experience and would
evoke significant symptoms of distress in almost
anyone (Brett, Spitzer, & Williams, 1988). The
absence of previous research on PTSD
associated with HIV + individuals suggests that
clinicians have been hesitant to view a diagnosis
of an illness as a traumatic event. Horowitz
argued that many individual experience
symptoms associated with PTSD as a response
to events that are not outside the range of human
experience but are nevertheless shocking and
uncommon experiences for the individual who
undergoes them for the first time. He further
stated that when an external event precipitates
intrusive thinking as well as other cardinal
symptoms of post-traumatic stress, this
diagnosis is more appropriate than that of an
Adjustment Disorder, which is less
symptomatically specific (Horowitz, 1986).
The diagnosis with a terminal illness such as
in the case with HIV infection, however, can
result in either a traumatic stress event, or a
chronic stress environment. Researchers have
viewed these two conditions as mutually
exclusive. It is generally believed that a chronic
stress environment will supersede traumatic
HIV Stress Response
stress in that the anxiety producing threats are
constantly present and intruding on the patient's
life experience (Foa, Seketee, & Rothbaum
1989). However, HIV illness has presented some
unique challenges to both medicine and
psychology. Many HIV+ individuals can go for
years without any medical symptoms or need for
treatment. These individuals' positive test result
can be viewed as a discrete traumatic event
without the chronic stressors typically present
when diagnosed with a potentially terminal
medical condition. Research has also
documented a discernable difference in
symptom presentation between individuals
suffering from chronic stress and those suffering
from unresolved traumatic stress based on the
presence of intrusion and avoidance symptoms
(Brett, Spitzer & Williams, 1988).
In this study, both symptomatic and
asymptomatic HIV + individuals endorsed a
high rate of PTSD symptoms on the IES. 92
percent of the HIV + subjects reported avoiding
letting themselves get upset when they thought
about it or were reminded of it. 92 percent of
these subjects also endorsed the intrusion
symptom of “other things kept making me think
about it.” 89 percent of HIV+ subjects reported
that they thought about it when they did not
mean to. 85 percent of the subject stated that
they at least once that week had had waves of
strong feelings about it. 84 percent of the
subjects reported that their feelings about it were
kind of numb. The high level of endorsement of
both intrusion and avoidance symptoms strongly
suggested that these individuals experienced
symptoms more diagnostic of PTSD than of
general anxiety.
Research has indicated that untreated PTSD
symptoms can continue to exist long after a
traumatic event (Keane, 1989). This raised the
question, "Can unresolved symptoms of PTSD
co-exist with a chronic stress condition?"
Although this research did not address this issue
directly, the prominence of PTSD symptoms in
both symptomatic and asymptomatic individuals
suggested that PTSD symptoms and chronic
stress symptoms may not be mutually exclusive.
Additional research that examines betweengroup differences for symptomatic and
asymptomatic HIV+ individuals by using a
PTSD measure such as the IES, and a reliable
Page 16
measure of generalized anxiety symptoms is
recommended to explore further whether PTSD
and chronic stress conditions must be mutually
exclusive.
Research of this type could have broad
implications particularly in the area of health
psychology. Because conditions such as cancer
and heart attacks are typically viewed as chronic
stress environments, they are often not viewed
as discrete traumatic events, and PTSD
treatment strategies are seldom employed.
However, if PTSD and chronic stress conditions
are not mutually exclusive, separate treatment
goals may be appropriate for the integration of
the traumatic diagnostic event, and the chronic
stress implications of the illness. Secondly,
research has indicated that medical conditions
such as cancer and heart attacks frequently result
in significant emotional difficulties after the
medical aspects of the illness have been resolved
(Hackett & Cassem 1970). It is theoretically
possible that PTSD symptoms may emerge after
the chronic stress environment is resolved if this
condition was initially ignored and untreated.
HIV illness may offer psychology a unique
opportunity to explore the relationship between
PTSD symptoms and the symptoms of anxiety
that result from the chronic stress caused by
medical illness. Because HIV + individuals may
experience the traumatic event of a positive test
finding years before the presence of chronic
illness, between-group studies and longitudinal
studies on this population could significantly
add to our understanding of PTSD as it relates to
the family of stress reactions and anxiety
disorders.
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