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 • • • • 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 • • • • • • 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) • • • • • 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) • • • • 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 • • • • • • • • Chest pain Choking sensation Diarrhea Diaphoresis Dyspnea Fatigue Flushing Headache • • • • • • • • Hyperventilation Muscle tension Nausea Palpitations Parasthesias Tachycardia Vertigo Vomiting American Psychiatric Association Office on HIV Psychiatry- Anxiety 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 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 • • • • • • • • • 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 • • • • • Alcohol Amphetamines Benzodiazepines Caffeine Cocaine • • • • • 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 • • • • • 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 – – – – – – – 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 – – – – 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