Original ArticlesPosttraumatic stress disorder in response to HIV infection
Introduction
Considerable debate has arisen recently regarding the nature and severity of the events that may give rise to a posttraumatic stress disorder (PTSD) [1]. Early work in this field by Horowitz et al. [2] highlighted traumatic stress responses among individuals following recent surgery and major medical illness. DSM-IV has included the diagnosis of life-threatening illness as an event that may trigger PTSD [3] although there is little empirical evidence to validate this criteria.
It is important to understand the key elements of any event that may distinguish the incident defined as “trauma” from other adverse events in an individual’s life. Green [4] emphasises that all the events noted in DSM-III-R as examples of trauma involve exposure to death or injury, threat of death, or severe injury, requiring the latent dimension of “death encounter.”
Recent research reports have drawn attention to the potential for developing posttraumatic stress disorder following other medical illnesses and physical injury. Doerfler et al. [5] reported on a study of 50 men at 6–12 months following myocardial infarction and coronary artery bypass surgery, 4 of whom met criteria for PTSD using DSM-III criteria. A report of posttraumatic responses to acute physical injury has indicated that initial high Impact of Event Scale (IES) scores following injury predict the development of posttraumatic stress disorder at 6 months follow-up (which was detected in 7 of the 48 patients). Interestingly, measures of severity of injury failed to predict the development of PTSD [6].
Other reports concerning the occurrence of PTSD in response to medical illness, using structured interview assessment, have included studies of patients with recent myocardial infarction (5% developing PTSD) [7], burn injuries (7.7–20%) 8, 9, and those with cancer diagnoses (10%–22%) 10, 11. The application of PTSD in medical illness has also been seen in other studies using self-report symptoms measures such as the Impact of Event Scale 12, 13, 14, 15. Other studies using self-report instruments for PTSD symptoms have reported that 5%–10% of breast cancer patients (using the PTSD Checklist) [11], 12% of childhood leukemia survivors and up to 39% of their parents (using the PTSD Reaction Index) [16] describe symptoms indicating a severe level of posttraumatic stress symptoms. Case reports have also illustrated the traumatic stress-like symptoms that can be detected following acute medical events, e.g., as a sequelae of Guillian-Barre syndrome [17], and childbirth [18].
Green [4] has referred to “new types of catastrophe” such as the diagnosis or threat of HIV infection. Research to date with HIV-positive samples and among individuals with other medical illnesses has used the IES as a measure of distress triggered by the diagnosis of disease, and also as a measure of bereavement reactions [19]. An important question that arises from this previous research is whether it is appropriate to apply the concept of traumatic stress reactions and traumatic stress disorder to the psychological impact of persisting life-threatening illness with its frequently chronic course, such as in HIV infection. This is important in assessing the role of HIV diagnosis as a traumatic incident in which other stressful experiences may occur (e.g., adverse reactions to disclosure of HIV status, loss of employment, bereavement).
To address these questions, the impact of disease severity and disease progression as triggers to traumatic stress responses needs to be evaluated alongside the measurement of factors that have been associated with posttraumatic stress reactions in other populations, and that form the basis for multifactorial models of the etiology of PTSD 20, 21. These include measures of pretrauma psychological vulnerability (such as past trauma experiences, past psychological health, and measures of personality) as well as social support and the presence of other current adversity.
This study investigated the occurrence of posttraumatic stress disorder arising in response to a diagnosis of HIV infection (PTSD-HIV) (using the PTSD module of the Diagnostic Interview Schedule-III-R) and the relationship between PTSD and other psychiatric disorders in this population. This exploratory study also aimed to investigate clinical factors that influence the development of PTSD in response to HIV infection.
Section snippets
Methods
A cross-sectional study was conducted of a convenience sample of HIV antibody-positive homosexual and bisexual men. Recruitment was conducted through clinical services (e.g., specialist HIV outpatient clinics), community AIDS/HIV support services and agencies, and volunteer organizations. This approach to recruitment is similar to methods used in other studies of psychiatric morbidity in HIV infection [22]. No subjects were directly recruited from either psychiatric inpatient or outpatient
Diagnostic interview schedule-version III-R (DIS) [23]
The DIS was used as a structured clinical interview to determine current and life-time rates of psychiatric disorder according to DSM-III-R diagnostic criteria. The following diagnostic sections of the DIS were used: affective disorders (major depression, dysthymic disorder, bipolar affective disorder), anxiety disorders, substance use disorders, schizophrenia, and schizo-affective states. The DIS has been developed as an instrument with high interrater reliability resulting from its highly
Statistical analysis
Comparison of groups classified according to a positive history of PTSD-HIV were conducted using the Chi-square test for categorical variables (e.g., disease staging, presence of other psychiatric disorders) and Student’s t-test for two group comparisons (e.g., comparing cases and noncases) on continuous variables. Multivariate analysis (discriminate function analysis) [31] was also used to investigate the factors that discriminate for a positive history of PTSD-HIV. Statistical significance
Sample
The sample comprised 61 HIV-positive homosexual/bisexual men. The mean duration since diagnosis of HIV infection was 47.8 months (range 4–96 months, SD = 25.1). The 61 HIV-positive men comprised 26 subjects in group CDC II/III (43%) and 35 (57%) in group CDC IV (57%). Of the CDC IV group, 37% (N = 13) were classified with CDC-IV group C1 disease (i.e., the presence of AIDS-defining secondary infectious diseases), and 34% as CDC-IV group C2 (N = 12) (i.e., other opportunistic infections such as
Posttraumatic stress disorder in response to HIV diagnosis
Nineteen participants (30.2%) fulfilled DSM-III-R diagnostic criteria for posttraumatic stress disorder in response to a diagnosis of HIV infection (PTSD-HIV). This refers to the presence of all clinical criteria for DSM-III-R posttraumatic stress disorder at any time following HIV diagnosis. Therefore the PTSD-HIV case group represents those with resolved as well as current PTSD.
A cut off of three or more endorsed PTSD symptoms is required before onset/recency and duration data are obtained.
Discussion
An investigation was undertaken applying the paradigm of traumatic stress response to medical illness by assessing PTSD in response to a diagnosis of HIV infection. The assessment of PTSD addresses symptoms of sufficient duration and severity to meet DSM-III-R criteria for a posttraumatic stress disorder, therefore a distinct clinical syndrome. The investigation of traumatic stress responses to HIV infection may also provide a theoretical and clinical framework in which to address the range of
Acknowledgements
This study was supported by a Commonwealth AIDS Research Grant. The authors wish to acknowledge the assistance of Ms Anna Zournazi, Dr. Cathe Buckham, Ms Virginia Munro, Ms Amanda Price, and Ms Dixie Statham, the participants, and staff of the clinical and other services assisting with the study.
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