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

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

HIV AND ANXIETY DISORDERS:

HIV-RELATED ANXIETY

American Psychiatric Association Office on HIV Psychiatry- 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

HIV AND ANXIETY DISORDERS:

EVALUATION AND DIAGNOSIS

American Psychiatric Association Office on HIV Psychiatry- Anxiety

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 Multiple Loss

General dysphoria/ Post-traumatic Depression 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

HIV AND ANXIETY DISORDERS:

DIFFERENTIAL DIAGNOSIS

American Psychiatric Association Office on HIV Psychiatry- Anxiety

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 • Benzodiazepine

s• Caffeine• Cocaine

• Ecstasy• GHB• Ketamine• Opiates• Nicotine

HIV AND ANXIETY DISORDERS:

TREATMENT APPROACHES

American Psychiatric Association Office on HIV Psychiatry- Anxiety

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