Cognitive Behavioral Stress Management and Secondary Prevention in HIV/AIDS
Neil Schneiderman, Ph.D., Michael Antoni, Ph.D., and Gail Ironson, M.D., Ph.D.
Updated by Kristina Rerucha, MPH (2011)
The recent advent of the protease inhibitors and triple combination therapies has brought about important improvements in the health care of AIDS patients. HIV/AIDS is now viewed as a chronic disease, in which patient management is an integral component. Patient management is optimal when patients are well-supported and have minimal psychological barriers. Because patient self-management is so important, psychosocial interventions focusing on stress management have become essential components of successful HIV management.
Cognitive behavioral stress management (CBSM) is a short-term therapeutic approach that focuses on how people’s thoughts affect their emotions and behaviors. It attempts to influence a client’s irrational thoughts while focusing directly on identifying and changing behaviors and thought patterns. CBSM protocols provide opportunities for psychologists to provide information, build a client’s emotional and interpersonal skills, and support patients through the process. During CBSM therapy, a client learns recovery skills that are useful throughout their lifetime. Techniques and skills that are acquired during CBSM therapy help facilitate adherence to medication protocols and have been shown to decrease isolation and depressive symptoms while improving immune function. Most importantly, CBSM improves quality of life for clients (Crepaz, et al., 2008; Brown & Vanable, 2008; Berger et al., 2007).
Investigators in the Behavioral Medicine Research Center at the University of Miami have examined relations among stress, immunity, and secondary prevention of HIV/AIDS for decades. The idea that patients can remain free of symptoms for a prolonged period, and that appropriate patient management could delay the onset of AIDS and ameliorate its course potential across the HIV disease spectrum was the impetus for our research. With these ideas, we came to view HIV as a chronic disease and utilized group- based cognitive behavioral stress management (CBSM) to improve quality of life and slowing symptom onset for those infected with HIV. Results from our investigations showed:
- CBSM can improve the HIV-infected person's quality of life by decreasing the distress and depressed affect associated with having a chronic and likely fatal disease. Further, by utilizing CBSM techniques, the subsequence use of acceptance and positive reframing strategies would inherently lead to increased, or maintained, social support.
- A psychosocial intervention facilitates adherence to good health practices and appropriate utilization of the health care system. This occurs by decreasing the use of maladaptive coping strategies, such as avoidance and denial, and instead using more problem-focused strategies.
- A CBSM intervention, including relaxation training, is able to attenuate the impact of stressors upon an already compromised immune system and in so doing might slow the course of immune decline that is observed in HIV spectrum disease.
Psychosocial Stressors, Coping, and HIV Progression
HIV-infected individuals face continual psychosocial stressors, which may include real or perceived social isolation, overwhelming medical costs, and continuous concerns over physical deterioration. While some HIV-infected individuals are able to effectively manage their care and lead fulfilling lives, a significant proportion report difficulties coping with stress (Heckman et al., 2004). Poor coping strategies contribute to poor disease management such as, adherence issues, missing medical appointments, etc. (Ironson et al., 2005) and thus increased morbidity and mortality risks.
Inadequate coping strategies for psychosocial stressors may lead to:
- Depressed affect;
- Increased psychological distress
- Hostility/further social isolation;
- Reduced social support utilization;
- High-risk sexual behavior;
- High prevalence of comorbid psychiatric problems;
- Diminished quality of life;
- Alcohol and/or drug abuse; and,
- Impaired immune functioning and possibly accelerated disease progression (Catz et al., 2002).
Conversely, positive coping skills, along with a high sense of coping self-efficacy, are associated with stress resistance and optimal psychological adjustment. Mulder and colleague’s(1995) research showed that HIV-infected individuals who used active coping strategies had fewer symptoms of HIV disease progression than those who did not. Additionally, planful problem solving as a coping technique is associated with decreased mortality (Eskild et al., 1998). Coping strategies, such as accepting a positive serostatus, or accepting circumstances “as is” have been found to predict slower disease progression (Thornton et al., 2000). However, when the acceptance carries a more fatalistic approach such as, “I prepare myself for the worst” faster disease progression has been observed (Reed et al., 1994).
In a review of positive psychosocial factors that predict HIV disease progression the most promising predictors were optimism, active coping, and spirituality (Ironson & Hayward, 2008). It is suggested that optimists tend to adopt healthier behaviors such as better adherence, more exercise, less illicit drug use, less smoking, more adaptive coping/proactive behaviors, less use of avoidant coping, and enhanced mood. A recent study found that HIV infected individuals who participated in spiritual activities had a reduced risk of morbidity (Fitzpatrick et al., 2007). The belief that “God is merciful” showed a protective effect of health over time. Conversely, those who believed that “God is judgmental and punishing and is going to judge me harshly some days” showed increased disease progression and poorer control of the virus, even with medications.
Good psychological adjustment and stress resistance are also associated with reduced disease progression. In their meta-analysis of cognitive behavioral interventions on HIV-positive persons, Crepaz and colleagues (2008) found HIV-infected individuals who received training on how to assess and alter their irrational thoughts, and who gained adaptive coping skills to manage and reduce their stress, showed significant improvement in psychological factors including depression, anxiety, anger, and stress when compared to the control group. Cognitive behavioral interventions are highly effective for helping improve psychological factors (Crepaz et al., 2008) and coping strategies for HIV infected individuals.
Stress Management Approaches
A meta-analysis about different CBI approaches found that interventions which incorporate stress management skills training and provide opportunities to increase self-efficacy through practice, were more successful than those that did not (Crepaz et al., 2008). In a review of the literature, Brown and Vanable (2008) concluded that stress management interventions are a promising approach to facilitate positive adjustment. From the 21 interventions reviewed, authors found that effective interventions included multiple sessions and numerous components. Unfortunately, consensuses of the active ingredients which can be replicated and incorporated into future stress management interventions were found.
A research proven, and validated, CBSM protocol appears in Stress Management for HIV: Clinical Validation and Intervention Manual by Antoni, Schneiderman and Ironson (2007). It is part of the Society of Behavioral Medicine's research-to-practice guidebook series and provides the rationale, validation data, manual and workbook for the intervention program.
A number of psychosocial intervention studies with HIV-infected individuals have been completed. The most consistent findings with regard to the psychological effects of CBSM interventions have been:
Decrease in distress and depressed affect;
Decrease in the use of avoidance and denial as coping strategies;
Increase in the use of acceptance and positive reframing strategies;
Increase quality of life; and,
Increase or maintenance of social support.
In summary, CBSM appears to have a significant role to play in the management of HIV spectrum disease. This includes ameliorating distress, improving patient adherence to medical regimens, and facilitating the efforts of HIV-infected women and men to cope effectively with their chronic disease accumulating in increased quality and quantity of life.
Antoni, M. H., Baggett, L., Ironson, G., LaPerriere, A., August, S., Klimas, N., Schneiderman, N., & Fletcher, M. (1991). Cognitive-behavioral stress management intervention buffers distress responses and immunologic changes following notification of HIV-1 seropositivity. Journal of Consulting and ClinicalPsychology, 59, 906-915.
Antoni, M. H., Schneiderman, N., & Ironson, G. (2007). Stress management for HIV: Clinical validation and intervention manual. Mahwah, NJ: Lawrence Erlbaum Associates.
Berger, S., Schad, T., von Wyl, V., Ehlert, U., Zellweger, C., … & Gaab, J. (2008). Effects of cognitive behavioral stress management on HIV-1 RNA, CD4 cell counts and psychosocial parameters of HIV-infected persons. AIDS, 22, 767-775.
Brown, J .L., Vanable, P. A. (2008). Cognitive-behavioral stress management interventions for persons living with HIV: A review and critique of the literature. Annals of Behavioral Medicine, 35(1), 26-40.
Catz, S., Gore-Felton, C., McClure, J. B. (2002). Psychological distress among minority and low-income women living with HIV. Behavioral Medicine, 28, 53-60.
Crepaz, N., Passin, W. F., Herbst, J. H., Rama, S., Malow, R. M., … & Wolitski, R.J. (2008). Meta-analysis of cognitive behavioral interventions on HIV-positive persons’ mental health and immune functioning. Health Psychology, 27(1), 4-14.
Esterling, B., Antoni, M. H., Schneiderman, N., LaPerriere, A., Ironson, G., Klimas, N., & Fletcher, M. A. (1992). Psychosocial modulation of antibody to Epstein-Barr Viral capsid antigen and Human Herpes Virus-Type 6 in HIV-1 infected and at-risk gay men. Psychosomatic Medicine, 54, 354-371.
Fitzpatrick, A. L., Standish, L. J., Berger, J., Kim, J., Calabrese, C., … & Polissar, N. (2007). Survivial in HIV-1 positive adults practicing psychological or spiritual activities for one year. Alternative Therapeutic Health Medicine, 13, 18-24.
Heckman, T. G., Anderson, E. S., & Sikkema, K. J. (2004). Emotional distress in nonmetropolitan persons living with HIV disease enrolled in a telephone-delivered, coping improvement group intervention. Health Psychology, 23, 94-100.
Ironson, G., Friedman, A., Klimas, N., Antoni, M., Fletcher, M. A., LaPerriere, A., Simoneau, J., & Schneiderman, N. (1994). Distress, denial and low adherence to behavioral interventions predict faster disease progression in gay men infected with Human Immunodeficiency Virus. International Journal of Behavioral Medicine, 1, 90-105.
Ironson, G., O’Cleirigh, C., & Fletcher, M. (2005). Psychosocial factors predict CD4 and viral load change in men and women with HIV in the era of HAART. Psychosomatic Medicine, 97, 1013-1021.
Ironson, G., & Hayward, H. (2008). Do positive psychosocial factors predict disease progression in HIV-1? A review of the evidence. Psychosomatic Medicine, 70(5), 546-554.
Lutgendorf, S. K., Antoni, M., Ironson, G., Klimas, N., Starr, K., Schneiderman, N., McCabe, P., Cleven, K., & Fletcher, M. A. (in press). Cognitive behavioral stress management intervention decreases dysphoric mood and herpes simplex virus-type 2 antibody titers in symptomatic HIV-seropositive gay men. Journal of Consulting and Clinical Psychology.
Mulder, C. L., Antoni, M. H., Duivenvoorden, H. J., Kauffman, R. G., & Goodkin, K. (1995). Active confrontational coping predicts decreased clinical progression over a one-year period in HIv-inected homosexual men. Journal of Pscychosomatic Research, 39, 957-965.
Reed, G. M., Kemey, M. E., Taylor, S. E., Wang, H. J., & Visscher, B. R. (1994). Realistic acceptance as a predictor of decreased survival time in gay men with AIDS. Health Psychology, 13, 299-307.
Schneiderman, N., Antoni, M., Ironson, G., Klimas, N., LaPerriere, A., Kumar, M., Esterling, B., & Fletcher, M. A. (1994). HIV-1, immunity and behavior. In R. Glaser, & J. Kiecolt-Glaser (Eds.), Handbook of human stress and immunity (pp. 267-300). NY: Academic Press.
Thornton, S., Troop, M., Burgess, A. P., Button, J., Goodall, R., … & Easterbrook, P. J. (2000). The relationship of psychological variables and disease progression among long-term HIV-infected men. International Journal of STD and AIDS, 11, 734-742.