1. HIV AND ANXIETY DISORDERS

2. 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

3. 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

4. American Psychiatric Association Office on HIV Psychiatry- Anxiety Outline HIV-Related Anxiety Evaluation and Diagnosis Differential Diagnosis Treatment Approaches

5. HIV AND ANXIETY DISORDERS: HIV-RELATED ANXIETY

6. American Psychiatric Association Office on HIV Psychiatry- Anxiety HIV-Related Anxiety Disorders Broad spectrum of syndromes Consider medical etiologies Normative anxiety symptoms

7. 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

8. 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.

9. 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

10. 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

11. American Psychiatric Association Office on HIV Psychiatry- Anxiety HIV Disease Related Anxiety (continued) Chronic pain syndromes Multi-system medical complications Death/dying preparation Bereavement

12. 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

13. HIV AND ANXIETY DISORDERS: EVALUATION AND DIAGNOSIS

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

22. American Psychiatric Association Office on HIV Psychiatry- Anxiety AIDS-Related Bereavement Single Loss Multiple Loss General dysphoria/ Post-traumatic Depression Distress “Multiple Loss Syndrome”

23. 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

24. HIV AND ANXIETY DISORDERS: DIFFERENTIAL DIAGNOSIS

25. 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

26. American Psychiatric Association Office on HIV Psychiatry- Anxiety Primary Psychiatric Disorders Adjustment disorders Depressive disorders Alcohol & other substance use disorders Bereavement (single vs. multiple)

27. 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

28. American Psychiatric Association Office on HIV Psychiatry- Anxiety Neuropsychiatric Disorders Neurocognitive disorders HIV-associated dementia Minor cognitive motor disorder Delirium

29. 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

30. 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

31. American Psychiatric Association Office on HIV Psychiatry- Anxiety Medications Associated with Anxiety (continued) Psychotropic side effects: –SSRIs –Venlafaxine –Bupropion –Psychostimulants –Neuroleptics

32. American Psychiatric Association Office on HIV Psychiatry- Anxiety Substance Use and Anxiety Alcohol Amphetamines Benzodiazepines Caffeine Cocaine Ecstasy GHB Ketamine Opiates Nicotine

33. HIV AND ANXIETY DISORDERS: TREATMENT APPROACHES

34. American Psychiatric Association Office on HIV Psychiatry- Anxiety Treatment of HIV-Related Anxiety Disorders Nonpharmacologic Pharmacologic

35. American Psychiatric Association Office on HIV Psychiatry- Anxiety Nonpharmacologic Interventions Avoid “reflexive” psychopharmacology When possible, start with nonpharmacologic treatments

36. 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

37. 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

38. 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

39. 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

40. 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

41. 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

42. American Psychiatric Association Office on HIV Psychiatry- Anxiety Pharmacotherapy (continued) Other anxiolytic agents –Beta-adrenergic blocking agents –Antihistamines –Other antidepressants Tricycles, mirtazapine –Neuroleptics

43. American Psychiatric Association Office on HIV Psychiatry- Anxiety HIV AND ANXIETY: CONCLUSIONS

44. 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

45. American Psychiatric Association Office on HIV Psychiatry- Anxiety