hiv and anxiety disorders. american psychiatric association office on hiv psychiatry- anxiety...

HIV AND ANXIETY

DISORDERS

American Psychiatric Association Office on HIV Psychiatry- Anxiety

Overview• Anxiety disorders are common in

HIV infection• Anxiety may be due to underlying

medical conditions or treatments• Anxiety disorders are treatable• Differentiating “normal” anxiety

from “abnormal” anxiety requires a diagnostic workup


Objectives

• To understand the spectrum of anxiety disorders prevalent in HIV infection

• To formulate a psychodynamic and pharmacological approach to anxiety in the HIV infected patient


Outline

• HIV-Related Anxiety• Evaluation and Diagnosis• Differential Diagnosis• Treatment Approaches

HIV AND ANXIETY DISORDERS:

HIV-RELATED ANXIETY


HIV-Related Anxiety Disorders

• Broad spectrum of syndromes• Consider medical etiologies• Normative anxiety symptoms


Epidemiology

• Prevalence of anxiety disorders: 2-40%

• Rates vary due to:– Sampling techniques– Psychosocial correlates– Comorbid depression and substance abuse

• Generally increased rates as illness progresses


Anxiety and HIV Disease Progression

• Disease-related events and stages (Milestones) of disease progression are frequently associated with the onset of anxiety symptoms or the worsening of pre-existing anxiety disorders.


HIV Disease Related Anxiety

• HIV testing• News of HIV positive status• Appearance of first illness

symptoms• Declining CD 4 counts• Increasing viral load• Onset of AIDS-defining illness


HIV Disease Related Anxiety (continued)

• Disclosure of HIV status • Initiation of multi-drug regimen• Negotiating a new sexual life• Onset of functional disabilities• Onset of cognitive disorders


HIV Disease Related Anxiety (continued)

• Chronic pain syndromes• Multi-system medical

complications• Death/dying preparation• Bereavement


Persons at High Risk for Anxiety Disorder

Diagnoses• Previous history of anxiety disorders• Psychosocial factors

– High stressful life events– Poor social support– Maladaptive coping strategies

• Unresolved grief– AIDS and non-AIDS related loss

• Medical factors– Pain– Advanced illness


EVALUATION AND DIAGNOSIS


Diagnostic Evaluation

• Baseline exam for new onset anxiety:– Detailed symptom profile

• Recent stressful events

– Drug/alcohol history– Current medication history– Assessment of suicidality– Past psychiatric history– Family history of anxiety disorders


Diagnostic Evaluation (continued)

• Baseline exam - continued:– Current medical status– Primary Axis I/Axis II disorders with

comorbid anxiety– Baseline laboratory evaluation

• Thyroid, liver and renal function


Screening for Psychosocial Predictors of

Anxiety• Stressor burden

– life events check-list/life experiences survey

• Social support– social support questionnaire

• Coping strategies– coping orientations to problems– coping checklist


Diagnosis

• Need specific DSM-IV criteria– Structured Clinical Interview for DSM-III-R

Non-Patient Version-HIV (SCID-NP-HIV) excludes HIV-related worries

– SCID-NP-HIV includes module for diagnosing HIV-specific adjustment disorders

– Modified Hamilton Anxiety Rating Scale for HIV eliminates some somatic anxiety symptoms


Autonomic/Somatic Symptoms

• Chest pain• Choking sensation• Diarrhea• Diaphoresis• Dyspnea• Fatigue• Flushing• Headache

• Hyperventilation• Muscle tension• Nausea• Palpitations• Parasthesias• Tachycardia• Vertigo• Vomiting


Primary Anxiety-Spectrum Disorders

• Panic disorder and agoraphobia• Social phobia and other phobias• Obsessive-compulsive disorder (OCD)• Post-traumatic stress disorder (PTSD)• Generalized anxiety disorder (GAD)• Acute stress disorder• Anxiety disorder due to medical

condition


Panic Disorder

• May be more common in HIV disease:– High lifetime prevalence of depressive

disorders with comorbid panic disorder– Association of panic disorder with viral

diseases– Association of panic disorder with

cocaine abuse and possibly with use of other substances


Post-traumatic Stress Disorder

• PTSD syndrome:– Observed in some persons who

receive positive HIV antibody test results • denial followed by nightmares, intrusive

thoughts about post-test notification

– Experienced by some persons with multiple AIDS-related losses


AIDS-Related Bereavement

Single Loss Multiple Loss

General dysphoria/ Post-traumatic Depression Distress

“Multiple Loss Syndrome”


AIDS-Related Bereavement (continued)

• Assess total loss burden – Partners, family, friends, community

impact• Assess stage of bereavement• Differentiate normal vs. complicated

bereavement• Evaluate for treatment

– Look for associated substance abuse and depression


DIFFERENTIAL DIAGNOSIS


Differential Diagnosis of Anxiety Disorders

• Primary psychiatric disorders– Anxiety disorders– Disorders with co-morbid anxiety

• Neuropsychiatric disorders• HIV-related complications

– Medical disorders– Medications


Primary Psychiatric Disorders

• Adjustment disorders• Depressive disorders• Alcohol & other substance use

disorders• Bereavement (single vs. multiple)


Adjustment Disorders

• Most commonly with anxious features

• If untreated, may progress to more severe anxiety disorders

• Rarely requires anxiolytic pharmacotherapy


Neuropsychiatric Disorders

• Neurocognitive disorders• HIV-associated dementia• Minor cognitive motor disorder

• Delirium


Medical Disorders and Anxiety

• Fever• Dehydration• Opportunistic CNS diseases• Neurosyphilis• Respiratory conditions• Endocrinopathies• Metabolic complications• Cardiovascular disease• Hyperventilation syndrome


Medications Associated with Anxiety

• HIV-related Medications– Acyclovir– Antiretrovirals (e.g., efavirenz) – Corticosteroids– Isoniazid– Interferons– Interleukin-2– Pentamidine


Medications Associated with Anxiety

(continued)

• Psychotropic side effects:– SSRIs– Venlafaxine– Bupropion– Psychostimulants– Neuroleptics


Substance Use and Anxiety

• Alcohol• Amphetamines • Benzodiazepine

s• Caffeine• Cocaine

• Ecstasy• GHB• Ketamine• Opiates• Nicotine


TREATMENT APPROACHES


Treatment of HIV-Related Anxiety Disorders

• Nonpharmacologic• Pharmacologic


Nonpharmacologic Interventions

• Avoid “reflexive” psychopharmacology

• When possible, start with nonpharmacologic treatments


Advantages of Nonpharmacologic

Interventions• Avoid polypharmacy• Decrease pill burden• Decreases CNS sedation & cognitive

impairment• Avoid drug-drug interactions• Avoid relapse of psychoactive

substance abuse• Interventions are typically effective


Anxiety Prevention Strategies

• Discuss trajectory of HIV illness• Allow adequate time for patient education• Assess patient - provider fit• Integrate care with continuity of providers• Establish social network:

– Food, housing/shelter, family, social support

• Crisis/emergency contact• May be able to prevent transition of AD to

GAD


Nonpharmacologic Therapies to Reduce

Anxiety• Muscle relaxation

therapies• Meditation

techniques• Individual

psychotherapy• Psychoeducation• Aerobic exercise• Electromyographic

biofeedback

• Behavioral techniques

• Acupuncture• Self-hypnosis &

imagery• Cognitive behavioral

therapy• Supportive group

therapy


Pharmacotherapy

• Benzodiazepines– Best used for time-limited treatment– Dependence/withdrawal possible– Low doses are often adequate– Drug-drug interactions possible

• Cytochrome P450 inhibition– Protease inhibitors

– Fewer P450 interactions with lorazepam, oxazepam, temazepam


Pharmacotherapy (continued)

• Buspirone– No acute effects– Advise patient of delay– Hepatically metabolized– Possible dizziness, headache, nervousness– Nonlethal in overdose– No abuse potential– Use with MAO inhibitors contraindicated



• Venlafaxine– Approved for treatment of GAD– Few drug-drug interactions– No abuse potential– GI c/o may be important because of antiretrovirals

• SSRI’s– May be helpful for several syndromes

• Social phobia, panic disorder, OCD, PTSD, GAD• Nefazodone may be helpful in agitated

depression



• Other anxiolytic agents– Beta-adrenergic blocking agents– Antihistamines– Other antidepressants

• Tricycles, mirtazapine

– Neuroleptics


HIV AND ANXIETY:

CONCLUSIONS


Conclusions

• Common in the setting of HIV infection

• Pivotal points in disease progression• Require differential diagnosis to rule

out medical etiologies• Treatable

– Nonpharmacologic approaches– Pharmacotherapy

hiv and anxiety disorders. american psychiatric association office on hiv psychiatry- anxiety...

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