Many HIV-positive gay men have post-traumatic stress disorder

A third of HIV-positive gay men have post-traumatic stress disorder, UK investigators report in AIDS Patient Care and STDs. Events including starting treatment, HIV-related illness, and witnessing an HIV-related death were all linked to the development of symptoms associated with post-traumatic stress disorder. Emotional responses to such events - rather than actual physical threat - were associated with the development of symptoms of posttraumatic stress.

“A wide range of HIV-related events can be of traumatic intensity for some individuals”, comment the researchers.

Life-threatening illness is recognised as a possible stressor that can lead to the development of post-traumatic stress disorder. In a standard text book for the diagnosis of mental disorders (Diagnostic and Statistical Manual of Mental Disorders, 4^th Edition Text Revision) this stress is defined as “the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury or threat to the physical integrity of self and others”, with the individual’s emotional response involving “fear, helplessness, or horror.”

Investigators wished to see if a broad-range of HIV-related events were associated with the development of post-traumatic stress disorder. They hypothesised that experiencing one or more events would be linked with symptoms of post-traumatic stress, and that perceived threat and emotional distress would be associated with such symptoms. They also wished to see if shame-related emotions were associated with post-traumatic stress symptoms.

Their study sample included 100 HIV-positive gay men. These individuals were self-selecting, collecting their study questionnaire from an HIV service provider or downloaded it from the internet.

The patients had a mean age of 43 years, the mean number of years since diagnosis with HIV was eight, most (95%) were white, 68% had received a college education, 47% were employed, and 56% defined themselves as being single.

Overall, 33%of the sample met the diagnostic criteria for posttraumatic stress disorder.

Over half the sample (55%) reported that their HIV diagnosis was traumatic, 40% said that the experience of HIV-related symptoms caused trauma, and 30% said that they were traumatised by witnessing a death related to HIV. Other traumatic events included starting HIV treatment (19%), experiencing treatment side-effects (29%) and self-disclosing HIV status (15%).

Experiencing HIV-related symptoms was associated with feelings of physical threat, leading to the development of stress disorder.

For all the other measures emotional distress – fear, helplessness, or horror - was associated with the symptoms of post-traumatic stress.

The only socio-demographic characteristic associated with an increased risk of reporting symptoms of post-traumatic stress was under- or unemployment (p < 0.05).

Physical symptoms (p < 0.01) and witnessing an HIV-related death (p < 0.05) were all significantly associated with symptoms of traumatic stress. The investigators believe that such experiences may immediately recall the “immediate threat posed by HIV.”

The investigators were surprised to find that starting HIV treatment (p < 0.01) was strongly associated with symptoms of post-traumatic stress. Few people (27%) perceived treatment as being physically threatening. The investigators speculated that there may be “catastrophic expectations about the limitations [treatment] may impose on social or occupational functioning, thus leading to traumatic fear, or the perceived failure of…lifestyle remedies leading to traumatic helplessness.”

The inclusion of shame-related emotions in the investigators’ analysis only modestly increased the proportion of patients who could be said to have experienced a traumatic event.

Individuals living with HIV can experience long periods of good health and stability, note the investigators. However, they suggest that receiving bad test results or witnessing HIV-related illness and death could cause “intense fear, helplessness or horror” that can predict the development of symptoms of post-tr aumatic stress. They recommend that HIV doctors should be watchful for symptoms such as “reexperiencing the event, behavioural avoidance or emotional numbing.”

Limitations of the study include its cross-sectional design. The investigators also acknowledge that they were unable to control for potentially confounding factors such as social support, non-HIV-related stressors, stigma, stressful life events, and past mental health problems.

Nevertheless, the investigators believe that their study adds to the literature that associates HIV with posttraumatic stress and that this is “primarily associated with fear, helplessness, or horror as opposed to shame, humiliation, or guilt.”