HIV AND ANXIETY DISORDERS - American Psychiatric Association

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HIV AND
ANXIETY DISORDERS
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
American Psychiatric Association Office on HIV Psychiatry- Anxiety
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
American Psychiatric Association Office on HIV Psychiatry- Anxiety
Outline
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HIV-Related Anxiety
Evaluation and Diagnosis
Differential Diagnosis
Treatment Approaches
American Psychiatric Association Office on HIV Psychiatry- Anxiety
HIV AND ANXIETY DISORDERS:
HIV-RELATED
ANXIETY
HIV-Related Anxiety Disorders
• Broad spectrum of syndromes
• Consider medical etiologies
• Normative anxiety symptoms
American Psychiatric Association Office on HIV Psychiatry- Anxiety
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
American Psychiatric Association Office on HIV Psychiatry- Anxiety
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.
American Psychiatric Association Office on HIV Psychiatry- Anxiety
HIV Disease Related Anxiety
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HIV testing
News of HIV positive status
Appearance of first illness symptoms
Declining CD 4 counts
Increasing viral load
Onset of AIDS-defining illness
American Psychiatric Association Office on HIV Psychiatry- Anxiety
HIV Disease Related Anxiety
(continued)
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Disclosure of HIV status
Initiation of multi-drug regimen
Negotiating a new sexual life
Onset of functional disabilities
Onset of cognitive disorders
American Psychiatric Association Office on HIV Psychiatry- Anxiety
HIV Disease Related Anxiety
(continued)
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Chronic pain syndromes
Multi-system medical complications
Death/dying preparation
Bereavement
American Psychiatric Association Office on HIV Psychiatry- Anxiety
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
American Psychiatric Association Office on HIV Psychiatry- Anxiety
HIV AND ANXIETY DISORDERS:
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
American Psychiatric Association Office on HIV Psychiatry- Anxiety
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
American Psychiatric Association Office on HIV Psychiatry- Anxiety
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
American Psychiatric Association Office on HIV Psychiatry- Anxiety
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
American Psychiatric Association Office on HIV Psychiatry- Anxiety
Autonomic/Somatic Symptoms
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Chest pain
Choking sensation
Diarrhea
Diaphoresis
Dyspnea
Fatigue
Flushing
Headache
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Hyperventilation
Muscle tension
Nausea
Palpitations
Parasthesias
Tachycardia
Vertigo
Vomiting
American Psychiatric Association Office on HIV Psychiatry- Anxiety
Primary Anxiety-Spectrum
Disorders
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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
American Psychiatric Association Office on HIV Psychiatry- Anxiety
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
American Psychiatric Association Office on HIV Psychiatry- Anxiety
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
American Psychiatric Association Office on HIV Psychiatry- Anxiety
AIDS-Related Bereavement
Single Loss
General dysphoria/
Depression
Multiple Loss
Post-traumatic
Distress
“Multiple Loss
Syndrome”
American Psychiatric Association Office on HIV Psychiatry- Anxiety
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
American Psychiatric Association Office on HIV Psychiatry- Anxiety
HIV AND ANXIETY DISORDERS:
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
American Psychiatric Association Office on HIV Psychiatry- Anxiety
Primary Psychiatric Disorders
• Adjustment disorders
• Depressive disorders
• Alcohol & other substance use
disorders
• Bereavement (single vs. multiple)
American Psychiatric Association Office on HIV Psychiatry- Anxiety
Adjustment Disorders
• Most commonly with anxious features
• If untreated, may progress to more
severe anxiety disorders
• Rarely requires anxiolytic
pharmacotherapy
American Psychiatric Association Office on HIV Psychiatry- Anxiety
Neuropsychiatric Disorders
• Neurocognitive disorders
• HIV-associated dementia
• Minor cognitive motor disorder
• Delirium
American Psychiatric Association Office on HIV Psychiatry- Anxiety
Medical Disorders and Anxiety
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Fever
Dehydration
Opportunistic CNS diseases
Neurosyphilis
Respiratory conditions
Endocrinopathies
Metabolic complications
Cardiovascular disease
Hyperventilation syndrome
American Psychiatric Association Office on HIV Psychiatry- Anxiety
Medications
Associated with Anxiety
• HIV-related Medications
– Acyclovir
– Antiretrovirals (e.g., efavirenz)
– Corticosteroids
– Isoniazid
– Interferons
– Interleukin-2
– Pentamidine
American Psychiatric Association Office on HIV Psychiatry- Anxiety
Medications
Associated with Anxiety
(continued)
• Psychotropic side effects:
– SSRIs
– Venlafaxine
– Bupropion
– Psychostimulants
– Neuroleptics
American Psychiatric Association Office on HIV Psychiatry- Anxiety
Substance Use and Anxiety
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Alcohol
Amphetamines
Benzodiazepines
Caffeine
Cocaine
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Ecstasy
GHB
Ketamine
Opiates
Nicotine
American Psychiatric Association Office on HIV Psychiatry- Anxiety
HIV AND ANXIETY DISORDERS:
TREATMENT
APPROACHES
Treatment of HIV-Related
Anxiety Disorders
• Nonpharmacologic
• Pharmacologic
American Psychiatric Association Office on HIV Psychiatry- Anxiety
Nonpharmacologic
Interventions
• Avoid “reflexive” psychopharmacology
• When possible, start with
nonpharmacologic treatments
American Psychiatric Association Office on HIV Psychiatry- Anxiety
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
American Psychiatric Association Office on HIV Psychiatry- Anxiety
Anxiety Prevention Strategies
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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
American Psychiatric Association Office on HIV Psychiatry- Anxiety
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
American Psychiatric Association Office on HIV Psychiatry- Anxiety
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
American Psychiatric Association Office on HIV Psychiatry- Anxiety
Pharmacotherapy
(continued)
• Buspirone
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No acute effects
Advise patient of delay
Hepatically metabolized
Possible dizziness, headache, nervousness
Nonlethal in overdose
No abuse potential
Use with MAO inhibitors contraindicated
American Psychiatric Association Office on HIV Psychiatry- Anxiety
Pharmacotherapy
(continued)
• Venlafaxine
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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
American Psychiatric Association Office on HIV Psychiatry- Anxiety
Pharmacotherapy
(continued)
• Other anxiolytic agents
– Beta-adrenergic blocking agents
– Antihistamines
– Other antidepressants
• Tricycles, mirtazapine
– Neuroleptics
American Psychiatric Association Office on HIV Psychiatry- Anxiety
HIV AND ANXIETY:
CONCLUSIONS
American Psychiatric Association Office on HIV Psychiatry- Anxiety
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
American Psychiatric Association Office on HIV Psychiatry- Anxiety
American Psychiatric Association Office on HIV Psychiatry- Anxiety
American Psychiatric Association Office on HIV Psychiatry- Anxiety
American Psychiatric Association Office on HIV Psychiatry- Anxiety
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