Changes in cognitive coping skills and social support during cognitive behavioral stress management intervention and distress outcomes in symptomatic human immunodeficiency virus (HIV)-seropositive gay men

OBJECTIVE

We have previously reported decreases in dysphoria, anxiety, and total mood disturbance in symptomatic HIV seropositive gay men after a 10-week cognitive behavioral stress management (CBSM) group intervention. This structured intervention was designed a) to increase cognitive and behavioral coping skills related to managing the distress of symptomatic HIV, and b) to increase social support among group members. Here we examine the relative contribution of changes in coping skills and social support during the intervention period to reductions in dysphoria, anxiety, and distress-related symptoms in this sample.

METHODS

Participants were randomized to a 10-week CBSM group intervention or to a wait-list control condition. Coping, social supports, and mood were measured before and after the intervention period.

RESULTS

Members of the CBSM group (N = 22) showed significant improvement in cognitive coping strategies involving positive reframing and acceptance, and in social supports involving attachment, alliances, and guidance at the end of the 10-week CBSM program compared with controls (N = 18) who showed decrements in these coping abilities and no changes in social support. Improved cognitive coping, specifically acceptance of the HIV infection, was strongly related to lower dysphoria, anxiety, and total mood disturbance in both conditions. Changes in social support and in cognitive coping skills seem to mediate the effects of the experimental condition on the changes in distress noted during the intervention.

CONCLUSIONS

These results suggest that cognitive coping and social support factors can be modified by psychosocial interventions and may be important determinants of the changes in psychological well-being and quality of life during symptomatic HIV infection that can be achieved through this form of intervention.

Measurement of perceived disruption during rebuilding following Hurricane Andrew

The purpose of this study was to develop and evaluate a measure of perceived disruption during rebuilding following a disaster. Two eight-item scales, which measured intensity of disruption during the entire repair phase (Intensity-RP) and intensity of disruption during the past month (Intensity-PM) were developed and administered to 135 survivors of Hurricane Andrew. At 9 to 12 months postdisaster, Intensity-RP and Intensity-PM were both significantly associated with scores on the Global Severity Index of the SCL-90-R, and with scores on the Impact of Event-Intrusion Scale; Intensity-PM alone was significantly associated with PTSD scores. Regression analyses indicated that each scale contributed significant unique variance in predicting mental health symptoms, even after controlling for relevant demographic and initial disaster exposure variables.

Coping self-efficacy buffers psychological and physiological disturbances in HIV-infected men following a natural disaster

The importance of coping self-efficacy (CSE) appraisals on psychological and physiological functioning for HIV seropositive patients facing a severe environmental stressor was tested comparing 37 HIV-infected gay men and 42 healthy male control participants following Hurricane Andrew. Results suggested that greater levels of CSE were related to lower emotional distress and posttraumatic stress disorder (PTSD) symptoms in both groups. In addition, greater CSE was associated with lower norepinephrine to cortisol ratios in the HIV group but not in the healthy control group. Results are discussed in relation to the coping process for HIV-infected individuals specifically and chronically ill populations in general who face severe environmental stressors.

Change in CD4+ cell enumeration following aerobic exercise training in HIV-1 disease: possible mechanisms and practical applications

Growing evidence suggests that routine physical activity, by individuals who are HIV-1 infected, may have significant impact on several important components of good health. Some of the physical benefits noted are: an increase in cardiopulmonary fitness, improved muscle function, and weight gain, while psychological benefits consisting of improved mood states and increased active coping behaviors have been observed. However, the emphasis of this paper is on the effects of exercise training on the enumeration of CD4+ cells in HIV/AIDS. A review of all the available literature revealed: (1) no decline in CD+ cell counts seen in any of the studies, regardless of the initial stage of disease, level of CD4+ cells, or symptomatology; (2) a trend toward an increase in the number of CD4+ cells in all but one study, with the more significant increases seen in those subjects at earlier stages of disease; and (3) the importance of homogeneous study samples when investigating the effects of exercise in a dynamic disease, such as HIV/AIDS. With regard to possible mechanisms, psychological stress has been implicated among the cofactors contributing to the immunological decline in HIV-1 disease. Good evidence was presented which supports the stress management role of exercise training as a means to explain the buffering of these suppressive stressor effects, thereby facilitating a return of the CD4+ cell count to more normal levels. We therefore believe that the observed elevation in the number of CD4+ cells actually represents a normalization of CD4+ cells. With regards to practical application, collectively these studies provide reason to encourage HIV-1 infected individuals to begin an exercise training program, preferably while they are in the early stages of disease, and in compliance with the suggested guidelines.

Posttraumatic stress symptoms, intrusive thoughts, loss, and immune function after Hurricane Andrew

OBJECTIVE

To examine the impact of and relationship between exposure to Hurricane Andrew, a severe stressor, posttraumatic stress symptoms and immune measures.

METHODS

Blood draws and questionnaires were taken from community volunteer subjects living in the damaged neighborhoods between 1 and 4 months after the Hurricane.

RESULTS

The sample exhibited high levels of posttraumatic stress symptoms by questionnaire (33% overall; 76% with at least one symptom cluster), and 44% scored in the high impact range on the Impact of Events (IES) scale. A substantial proportion of variance in posttraumatic stress symptoms could be accounted for by four hurricane experience variables (damage, loss, life threat, and injury), with perceived loss being the highest correlate. Of the five immune measures studied Natural Killer Cell Cytotoxicity (NKCC) was the only measure that was meaningfully related (negatively) to both damage and psychological variables (loss, intrusive thoughts, and posttraumatic stress disorder (PTSD). White blood cell counts (WBCs) were significantly positively related with the degree of loss and PTSD experienced. Both NKCC (lower) and WBC were significantly related to retrospective self-reported increase of somatic symptoms after the hurricane. Overall, the community sample was significantly lower in NKCC, CD4 and CD8 number, and higher in NK cell number compared to laboratory controls. Finally, evidence was found for new onset of sleep problems as a mediator of the posttraumatic symptom-NKCC relationship.

CONCLUSIONS

Several immune measures differed from controls after Hurricane Andrew. Negative (intrusive) thoughts and PTSD were related to lower NKCC. Loss was a key correlate of both posttraumatic symptoms and immune (NKCC, WBC) measures.

Cognitive-behavioral stress management decreases dysphoric mood and herpes simplex virus-type 2 antibody titers in symptomatic HIV-seropositive gay men

This study tested the effects of a 10-week group cognitive-behavioral stress management (CBSM) intervention on mood and immunologic parameters in HIV-seropositive gay men whose disease had progressed to a symptomatic stage. Men were randomized to either CBSM or a modified waiting-list control group. The CBSM intervention significantly decreased self-reported dysphoria, anxiety, and total distress. Individuals who practiced relaxation more consistently had significantly greater drops in dysphoria. The intervention also decreased herpes simplex virus-Type 2 (HSV-2) immunoglobulin G antibody titers. The control group showed no significant changes in either mood or antibody titers. Individual difference analyses revealed that decreases in dysphoria significantly predicted lower HSV-2 antibody titers by the end of the 10-week period. Neither group displayed changes in HSV-Type 1 antibody titers or in CD4+ or CD8+ cell numbers.

Massage therapy reduces anxiety and enhances EEG pattern of alertness and math computations

Twenty-six adults were given a chair massage and 24 control group adults were asked to relax in the massage chair for 15 minutes, two times per week for five weeks. On the first and last days of the study they were monitored for EEG, before, during and after the sessions. In addition, before and after the sessions they performed math computations, they completed POMS Depression and State Anxiety Scales and they provided a saliva sample for cortisol. At the beginning of the sessions they completed Life Events, Job Stress and Chronic POMS Depression Scales. Group by repeated measures and post hoc analyses revealed the following: 1) frontal delta power increased for both groups, suggesting relaxation; 2) the massage group showed decreased frontal alpha and beta power (suggesting enhanced alertness); while the control group showed increased alpha and beta power; 3) the massage group showed increased speed and accuracy on math computations while the control group did not change; 4) anxiety levels were lower following the massage but not the control sessions, although mood state was less depressed following both the massage and control sessions; 5) salivary cortisol levels were lower following the massage but not the control sessions but only on the first day; and 6) at the end of the 5 week period depression scores were lower for both groups but job stress score were lower only for the massage group.

Psychiatric morbidity following Hurricane Andrew

The nature of psychiatric morbidity in previously non-ill subjects from the area most affected by Hurricane Andrew was investigated at 6-12 months posthurricane. Preliminary associations of morbidity with personal and event-related risk factors were also determined. Fifty one percent (31/61) met criteria for a new-onset disorder, including posttraumatic stress disorder (PTSD) in 36%, major depression (MD) in 30%, and other anxiety disorders in 20%. Thirty four subjects (56%) had significant symptoms persisting beyond 6 months. Having sustained "severe damage" was the risk factor most strongly associated with outcome. Our data underscore the range of psychiatric morbidity related to a natural disaster, and suggest a relationship to chronic stressors.

Massage therapy is associated with enhancement of the immune system's cytotoxic capacity

Twenty-nine gay men (20 HIV+, 9 HIV-) received daily massages for one month. A subset of 11 of the HIV+ subjects served as a within subject control group (one month with and without massages). Major immune findings for the effects of the month of massage included a significant increase in Natural Killer Cell number, Natural Killer Cell Cytotoxicity, soluble CD8, and the cytotoxic subset of CD8 cells. There were no changes in HIV disease progression markers (CD4, CD4/CD8 ratio, Beta-2 microglobulin, neopterin). Major neuroendocrine findings, measured via 24 hour urines included a significant decrease in cortisol, and nonsignificant trends toward decrease of catecholamines. There were also significant decreases in anxiety and increases in relaxation which were significantly correlated with increases in NK cell number. Thus, there appears to be an increase in cytotoxic capacity associated with massage. Implications for HIV+ men as those with other illnesses, particularly cancer, are discussed.

Physical symptoms of chronic fatigue syndrome are exacerbated by the stress of Hurricane Andrew

This study examined the effects of Hurricane Andrew on physical symptoms and functional impairments in a sample of chronic fatigue syndrome (CFS) patients residing in South Florida. In the months after Hurricane Andrew (September 15-December 31, 1992), 49 CFS patients were assessed for psychosocial and physical functioning with questionnaires, interviews, and physical examinations. This sample was made up of 25 CFS patients living in Dade county, a high impact area, and 24 patients in Broward and Palm Beach counties, areas less affected by the hurricane. Based on our model for stress-related effects on CFS, we tested the hypothesis that the patients who had the greatest exposure to this natural disaster would show the greatest exacerbation in CFS symptoms and related impairments in activities of daily living (illness burden). In support of this hypothesis, we found that the Dade county patients showed significant increases in physician-rated clinical relapses and exacerbations in frequency of several categories of self-reported CFS physical symptoms as compared to the Broward/Palm Beach county patients. Illness burden, as measured on the Sickness Impact Profile, also showed a significant increase in the Dade county patients. Although extent of disruption due to the storm was a significant factor in predicting relapse, the patient's posthurricane distress response was the single strongest predictor of the likelihood and severity of relapse and functional impairment. Additionally, optimism and social support were significantly associated with lower illness burden after the hurricane, above and beyond storm-related disruption and distress responses. These findings provide information on the impact of environmental stressors and psychosocial factors in the exacerbation of CFS symptoms.

Effects of aerobic exercise training on lymphocyte subpopulations

This study was conducted to determine the effects of an aerobic exercise training program on subpopulations of lymphocyte phenotypes. Fourteen healthy but sedentary males, 18-40 years of age, were randomly assigned to either an aerobic exercise training or control condition. Aerobic exercise training consisted of three 45-minute sessions of cycle ergometry exercise per week at 70-80% of age-predicted maximum heart rate for ten weeks. The aerobic exercise training resulted in a significant decrease in submaximal heart rate from 176 to 150 beats per minute to a fixed work rate of 150 watts (p < .01). This training effect was accompanied by increases in the resting level of the following lymphocyte subpopulations: CD2 (1717 vs 2183 mm3; p < .01), CD4 (942 vs 1280 mm3; p < .01), CD45RA+CD4+ (312 vs 595 mm3; p < .01), CD8 (655 vs 816 mm3; p < .05), and CD20 (162 vs 244 mm3; p < .01) cell counts. These findings indicate that several lymphocyte subpopulations are increased following a 10-week program of aerobic exercise training.

Exercise and psychoneuroimmunology

Psychoneuroimmunology is the study of the interrelationships among psychological, neuroendocrine, and immunological parameters and is concerned with how these relationships may affect an individual's health. Substantial evidence indicates that exercise is associated with improvements in mental health, neuroendocrine, and immune functioning. We synthesize these effects of exercise and propose an "exercise and psychoneuroimmunology" model by which exercise may benefit the psychologic and immunologic sequelae of several chronic diseases. For the past several years we have been investigating exercise training interventions, based on our model, for individuals infected with the human immunodeficiency virus type 1 (HIV-1). These studies indicate that a moderate exercise training program may attenuate the adverse stressor-induced psychologic and immunologic changes for asymptomatic HIV-1 seropositive individuals. In addition, our research indicates that continued aerobic exercise training may result in increased CD4 cell counts, immune surveillance, and a potential for a slowing of disease progression. Other researchers have demonstrated similar beneficial effects of exercise for individuals infected with HIV-1 who are at more advanced stages of disease. Exercise within the context of psychoneuroimmunology appears to be a very promising approach to the treatment of illness and promotion of health.

Psychosocial correlates of illness burden in chronic fatigue syndrome

We related reported physical symptoms, cognitive appraisals (e.g., negative style of thinking), and coping strategies (e.g., denial/disengagement strategies) with illness burden across several functional domains separately in subsets of chronic fatigue syndrome (CFS) patients with (n = 26) and without (n = 39) concurrently diagnosed major depressive disorder (MDD). In regard to cognitive appraisal measures, automatic thoughts and dysfunctional attitudes were strongly associated with a higher illness burden, as indicated in sickness impact profile (SIP) scores. Active-involvement coping strategies measured on COPE scales (active coping, planning, and positive reinterpretation and growth) were not associated with SIP scores, while other coping strategies (mental disengagement, behavioral disengagement, and denial) were positively correlated with psychosocial and physical SIP scales, especially those pertaining to interpersonal life-style arenas. After we accounted for the number of different CFS-specific physical complaints reported and DSM-III-R depression diagnosis status, cognitive appraisals and coping strategies predicted a substantial proportion of the variance in the severity of illness burden. For the most part, the magnitude of these relationships between our predictor model variables and illness burden severity was similar in the MDD and non-MDD subgroups.

Massage effects on cocaine-exposed preterm neonates

Thirty preterm cocaine-exposed preterm neonates (mean gestational age 30 wks, mean birth weight = 1212 g, mean intensive care unit duration = 18 days) were randomly assigned to a massage therapy or a control group as soon as they were considered medically stable. Group assignment was based on a random stratification of gestational age, birth weight, intensive care unit duration, and entry weight into the study. The treatment group (N = 15) received massages for three 15-minute periods 3 consecutive hours for a 10-day period. Findings suggested that the massaged infants (1) averaged 28% greater weight gain per day (33 vs 26 g) although the groups did not differ in intake (calories or volume), (2) showed significantly fewer postnatal complications and stress behaviors than did control infants, and (3) demonstrated more mature motor behaviors on the Brazelton examination at the end of the 10-day study period.

Effects of anger on left ventricular ejection fraction in coronary artery disease

This study examined the comparative potency of several psychological stressors and exercise in eliciting myocardial ischemia as measured by left ventricular (LV) ejection fraction (EF) changes using radionuclide ventriculography. Twenty-seven subjects underwent both exercise (bicycle) and psychological stressors (mental arithmetic, recall of an incident that elicited anger, giving a short speech defending oneself against a charge of shoplifting) during which EF, blood pressure, heart rate and ST segment were measured. Eighteen subjects had 1-vessel coronary artery disease (CAD), defined by greater than 50% diameter stenosis in 1 artery as assessed by arteriography. Nine subjects served as healthy control subjects. Anger recall reduced EF more than exercise and the other psychological stressors (overall F [3.51] = 2.87, p = .05). Respective changes in EF for the CAD patients were -5% during anger recall, +2% during exercise, 0% during mental arithmetic and 0% during the speech stressor. More patients with CAD had significant reduction in EF (greater than or equal to 7%) during anger (7 of 18) than during exercise (4 of 18). The difference in EF change between patients with CAD and healthy control subjects was significant for both anger (t25 = 2.23, p = 0.04) and exercise (t25 = 2.63, p = 0.01) stressors. In this group of patients with CAD, anger appeared to be a particularly potent psychological stressor.

Psychosocial modulation of antibody to Epstein-Barr viral capsid antigen and human herpesvirus type-6 in HIV-1-infected and at-risk gay men

We investigated the effects of two behavioral interventions--aerobic exercise and cognitive behavioral stress management (CBSM)--on Epstein-Barr virus viral capsid antigen (EBV-VCA) and human herpesvirus type-6 (HHV-6) antibody modulation in 65 asymptomatic gay men measured at several time points in the 5 weeks preceding and following notification of their human immunodeficiency virus-type 1 (HIV-1) serostatus. After accounting for potential immunomodulatory confounds, we found that HIV-1 seropositive men had higher EBV-VCA antibody titers than those diagnosed as seronegative at every time point during the study; however, no significant differences were found with respect to HHV-6. Among HIV-1 seropositive and seronegative subjects, respectively, those randomized to either behavioral intervention had significant decreases in both EBV-VCA and HHV-6 antibody titers over the course of the intervention as compared with assessment-only controls (of HIV-1 seropositive and seronegative status) whose antibody titers did not significantly change and which remained consistently higher than either serostatus-matched intervention group over subsequent time points, independent of total immunoglobulin G levels and degree of polyclonal B cell activation. In attempting to explain serostatus differences in EBV and HHV-6 values, it was found that HIV-1 seropositive men had significantly lower CD4 cells, CD4:CD8 ratio, and blastogenic response to phytohemagglutinin (PHA), as well as significantly higher CD8 cells at baseline. No significant differences were found between the HIV-1 seropositive and seronegative men with respect to anxiety and depression at baseline. Since the greatest changes in EBV and HHV-6 occurred between baseline and week 10, we correlated changes in immune (CD4, CD8, CD4:CD8 ratio, PHA stimulation) and distress-related markers (state depression and anxiety) with EBV and HHV-6 change scores over this time period. No significant correlations were found between any of these immune- or distress-related variable and the antibody change scores suggesting that the mechanisms by which EBV and HHV-6 antibodies are being modulated by these interventions possibly involve other, yet to be determined, immune, neuroendocrine, and/or psychologic variables.

Endogenous depression in the elderly: prevalence and agreement among measures

This article describes agreement among diagnoses made according to five definitions of endogenous depression in a sample of 99 depressed elders and discusses the relationship among these systems and selected demographic and clinical characteristics. Poor to fair agreement was generally demonstrated, except for Research Diagnostic Criteria (Spitzer, Endicott, & Robins, 1978) and Diagnostic and Statistical Manual of Mental Disorders, 3rd ed., rev. (American Psychiatric Association, 1987), which demonstrated excellent agreement. Mostly, demographic and clinical variables (e.g., severity of depression) were unrelated to endogeneity diagnoses. The conclusion was reached that these criteria are not all measuring the same construct in older adults and that the relationship between depression severity and endogeneity should be discussed in terms of specific definitions rather than general terms.

Endogenous depression in the elderly: Prevalence and agreement among measures

This article describes agreement among diagnoses made according to five definitions of endogenous depression in a sample of 99 depressed elders and discusses the relationship among these systems and selected demographic and clinical characteristics. Poor to fair agreement was generally demonstrated, except for Research Diagnostic Criteria (Spitzer, Endicott, & Robins, 1978) and Diagnostic and Statistical Manual of Mental Disorders, 3rd ed., rev. (American Psychiatric Association, 1987), which demonstrated excellent agreement. Mostly, demographic and clinical variables (e.g., severity of depression) were unrelated to endogeneity diagnoses. The conclusion was reached that these criteria are not all measuring the same construct in older adults and that the relationship between depression severity and endogeneity should be discussed in terms of specific definitions rather than general terms.

Cognitive-behavioral stress management intervention buffers distress responses and immunologic changes following notification of HIV-1 seropositivity

Forty-seven asymptomatic, healthy gay men were randomly assigned to a cognitive-behavioral stress management (CBSM) condition or an assessment-only control group 5 weeks before being notified of their HIV-1 antibody status. Seventy-two hours before and 1 week after serostatus notification, blood samples and psychometric data were collected. Control subjects showed significant increases in depression, but only slight decrements in mitogen responsivity and lymphocyte cell counts pre- to postnotification of seropositivity. Seropositive CBSM Ss did not show significant pre-post changes in depression, but did reveal significant increases in helper-inducer (CD4) and natural killer (CD56) cell counts as well as a slight increment in proliferative responses to phytohemagglutinin (PHA). Individual difference analyses suggest that the psychological buffering and immunomodulating effects of the CBSM manipulation may be attributable, in part, to relaxation skills learned and practiced or to a general willingness to comply with the intervention guidelines.

Immunologic function in a cohort of human immunodeficiency virus type 1-seropositive and -negative healthy homosexual men

The study objectives were to determine the early effects of human immunodeficiency virus type 1 (HIV-1) infection on both phenotypic and functional immunologic markers in healthy homosexual men, to ascertain the relationships of these markers to each other, and to discover which markers were affected by enrollment in an AIDS study in which HIV-1 serostatus would be determined. The major findings were as follows. (i) The CD4/CD8 ratio and lymphocyte proliferative response to pokeweed mitogen were the characteristics most affected by early HIV-1 infection. (ii) The loss in CD4 cells observed in the HIV-1-positive homosexual men was entirely due to diminished numbers of the memory subset. CD4+ CD29+. The reciprocal subset of CD4, CD4+ CD45RA+, did not differ in the two groups of homosexual men at either time point or in the controls. (iii) Prior to learning their HIV-1 serostatus, HIV-1 antibody-negative risk-group males had lower phytohemagglutinin (PHA) responses than the controls did. In the assays following notification of their seronegativity, however, these men had PHA values which were not different from those of the controls. In the HIV-1-positive group, the responses to both PHA and pokeweed mitogen were below those of both HIV-1-negative groups and did not change after serostatus notification. (iv) The activity of natural killer cells was lower in the risk-group men than in the controls at both pre- and postdiagnosis but was not related to HIV-1 serostatus. (v) In this cohort of homosexual men, the CD4/CD8 ratio correlated significantly with the functional measures of immunologic status in the HIV-1-positive men, but not in the HIV-1-negative men.

Aerobic exercise training in an AIDS risk group

Increases in physical fitness are often associated with improvements in certain chronic diseases, such as hypertension and coronary heart disease. Recent evidence has shown that exercise also influences the neuroendocrine and immune systems, resulting in a potential to benefit those with chronic immunodeficiency diseases. Therefore, exercise may prove to have a profound impact on the management of the acquired immunodeficiency syndrome (AIDS). Our current work includes the investigation of the immunologic and stress-attenuating effects of an aerobic exercise training program for individuals at risk for AIDS. Upon completion of training, the subjects showed a significant increase in helper/inducer (CD4) cells and the inducer subset (CD45RA+CD4+) which activate suppressor/cytotoxic (CD8) cells. These increases, which average about 50 cells per cubic millimeter, are comparable to those observed in some studies of the AIDS drug comparable to those observed in some studies of the AIDS drug azidothymidine (AZT), but without the accompanying side effects. Also, individuals undergoing aerobic training reported no increases in anxiety and depression in response to notification of a positive HIV-1 serologic status. These findings taken together indicate that an aerobic exercise training program may enhance certain critical components of cellular immunity as well as acting as a buffer for the detrimental mood changes that typically accompany stress, thus providing a timely, promising behavioral approach to helping HIV-1-infected individuals.

Disparities in psychological, neuroendocrine, and immunologic patterns in asymptomatic HIV-1 seropositive and seronegative gay men

The present study concurrently measured psychological distress (state anxiety, depression, confusion, and intrusive thoughts), neuroendocrine (plasma cortisol concentrations), and immunologic [lymphocyte proliferative responses to phytohemagglutinin (PHA) and pokeweed mitogen (PWM)] changes in the 5-week periods preceding and following serostatus notification among asymptomatic Human Immunodeficiency Virus-type 1 (HIV-1) seropositive and seronegative gay men. Seropositives, as opposed to seronegatives, showed a disparity in predicted relationships among distress, cortisol, and immunologic measures across the prenotification to postnotification period. Individual difference analyses suggested that among seropositives, in contrast to seronegatives, plasma cortisol concentrations were negatively correlated with psychological distress and positively correlated with responses to PHA (assessed at study entry and after serostatus notification). This pattern in seropositives could not be explained by differences in prenotification perceived risk of infectivity, extraneous environmental stressors, or CD4 cell counts within the seropositive group.