HIV AND ANXIETY DISORDERS
Dec 19, 2015
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