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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. 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