Information on HIV/AIDS, Death Anxiety & Cognitive
Behavioral Therapy
Jeffrey W. Braunstein, Ph.D.
Epidemiology and
Description of HIV/AIDS Population
Over one million men,
women, and children worldwide have been diagnosed with the Acquired Immune
Deficiency Syndrome (AIDS) since it was identified in the early 1980s (World
Health Organization Global Statistics, 1995), and over 500,000 cases have been
documented in the United States (Center for Disease Control and Prevention
[CDC], 1993). The Center for Disease Control and Prevention estimated that an
additional one million people may be infected with the HIV virus (CDC, 1995).
AIDS is the leading
cause of death in the United States among persons between the ages of 25 and 44
(CDC, 1993). The highest rate of HIV transmission is occurring in Latino and
African American adolescents (CDC). The high risk groups for the adult
population are men who engage in sexual intercourse with men and male
intravenous drug users. Incidence of infection in adult women is rapidly
increasing. During the early period of the disease, hemophiliacs were infected
by contaminated blood during transfusions. Since 1985, the blood supply has
been routinely screened for HIV and infection by this route has significantly
decreased.
Transmission of HIV
HIV is a virus that infects white
blood cells, primarily CD4 cells, that are central parts of the immune system.
The virus eventually destroys CD4 cells, inhibits the effectiveness of immune
system functioning, disabling the body from fighting off infections and
disease. CD4 cells are found primarily in blood and genital secretions (semen,
vaginal fluids, menstrual blood). The HIV virus is primarily transmitted
through sexual intercourse and through contact with infected blood that enters
the bloodstream of the uninfected person. Sharing of syringes during
intravenous drug use is an additional method of contagion. A mother who is
infected can also pass the virus to her child during pregnancy and through
breast feeding. Injecting large amounts of infected blood during a transfusion
can easily transmit the virus. The HIV virus can be transmitted to health care
professionals by accidental needlestick injuries while treating HIV positive
patients.
The HIV virus has been found in the
tears and saliva of some HIV positive patients but in amounts too low to
transmit the virus (Bartlett and Finkbeiner, 1993). The HIV virus has not been
found in feces or urine. The skin and mucus membranes in the mouth are barriers
for the HIV virus. If skin is unbroken (sores and cuts leave a person
susceptible) the possibility for transmission of the virus is improbable.
Shaking hands, sharing a toilet, sharing eating utensils, being sneezed upon,
living in the same household, working in the same room, and closed mouth kissing
are biologically impossible ways for transmitting the virus.
Stages and Physical Manifestations of
HIV/AIDS
Acute Infection: Within one
to six weeks after the transmission of HIV, people develop symptoms that
resemble infectious mononucleosis. This stage lasts approximately one to two
weeks. These symptoms can go unnoticed. Bartlett and Finkbeiner (1993) report
that 50 to 90 percent of people with HIV infection experience symptoms, such as
fever, sweats, fatigue, joint pain, headaches, sore throat, difficulty
swallowing, that resemble infectious mononucleosis. During this stage,
traditional blood tests for the presence of HIV may be negative.
Seroconversion:
Seroconversion occurs within four to twelve weeks of infection. During this
stage, the body develops antibodies to HIV. Blood tests that detect the
presence of HIV are positive due to the immune systems production of antibodies
to HIV.
Asymptomatic Period: During
this period, people infected with HIV experience no symptoms of the disease but
remain capable of transmitting it to others. Formal HIV testing for the
presence of antibodies to HIV is the only way for the person to know if they are
infected. The asymptomatic period lasts approximately from five to eight
years. Specific strains of the virus can cause the disease to progress faster.
Virus exposure can also affect the progression. An increased number of viruses
that the person was exposed to during time of infection can decrease the length
of the asymptomatic period. Age is another important factor: children and the
elderly experience a shortened asymptomatic period. A person’s genetic
composition can also affect disease progression. Conclusive evidence has not
been obtained, but it is hypothesized that health factors such as mental health,
nutrition, and exercise may possibly effect the asymptomatic period.
During the asymptomatic period the
virus slowly infects and destroys CD4 cells. After a number of years, the
cumulative loss of CD4 cells disables the body from fighting off infections and
diseases. The average CD4 cell count in healthy people is approximately 1,000.
Symptoms usually do not develop until a person’s CD4 count is below 300. Severe
complications develop when the CD4 count is 50-100. Blood counts are routinely
performed to monitor the progression of the disease. Persistent Generalized
Lymphadenopathy (PGL) and persistent swollen lymph nodes can affect patients
during the asymptomatic period. Lymph nodes throughout the body can be swollen,
and painful but other symptoms of HIV are not present.
Early Symptomatic HIV Infection:
First symptoms of immune system dysfunction become evident during the early
symptomatic stage of infection. This period is also referred to as AIDS-related
complex (ARC). The symptoms and conditions that develop during this period
resemble but are not as severe as symptoms that define the diagnosis of AIDS.
“The most common early conditions are thrush, oral leukoplakia, shingles,
idiopathic thrombocytopenic purpura, and constitutional symptoms, which include
chronic fever, weight loss, and chronic diarrhea (Bartlett and Finkbeiner, 1993,
p. 64).”
Late Symptomatic HIV infection
(AIDS): Occurs approximately eight years after the time of infection. AIDS
defining conditions are opportunistic infections or tumors and a CD4 cell count
below 200. The most common opportunistic infections and tumors are Pneumocystis
carinii pneumonia (PCP) and Kaposi’s sarcoma (KS). PCP is an infection of the
lung. Eighty percent of all HIV patients eventually develop PCP and over
ninety-five of all people who develop PCP also are HIV positive (Bartlett and
Feinkbeiner, 1993). KS is a tumor of the blood vessels that is purple or black
in color and is usually painless. These tumors usually appear on the skin but
can also occur in the gastrointestinal tract, under the arms, in the groin, in
the neck, in the lungs, in the liver, in the brain, and within other organs.
Other conditions such as tuberculosis, encephalitis, meningitis, and herpes
simplex infection occur frequently as the immune system weakens.
Neuropsychological complications
frequently develop during the course of AIDS. AIDS Dementia Complex (ADC) is
the most common neurological complication of AIDS and is defined as global
cognitive impairment due to brain infection caused by HIV. Cognitive impairment
is usually characterized by mental slowing and deficits in memory and
attention. ADC also results in blunted affect, incontinence, gait problems,
ataxia, and other motor problems (Tross and Hirsch, 1988). Disorders of the
central nervous system also effect the neurological functioning of those
diagnosed with HIV and AIDS.
Death Anxiety
The Two-Factor Model of
Death Anxiety (Lester & Templer, 1993; Lonetto & Templer, 1986; Templer, 1976)
posits that death anxiety is composed of two factors. The first factor, overall
psychological health, reflects general psychopathology such as depression and
anxiety. The second factor reflects a person’s life experiences concerning the
topic of death and subsequent fear of death. This second factor is primarily
based on learning principles and environmental influences. A third “factor” of
an existential nature (e.g. death’s effect on the perception of life’s meaning)
has been suggested, encompassing variables not currently accounted for by the
first two factors (Lonetto & Templer, 1986; Templer, 1976).
A survey of the death
anxiety literature by Lonetto & Templer (1986) indicated that there is no
significant relationship between age and death anxiety. A few studies though
have reported a significant inverse relationship between age and death anxiety,
with the elderly exhibiting less death anxiety than younger populations
(Shusterman and Sechrest, 1973). Females exhibit higher death anxiety than
males (Lonetto & Templer, 1986). Male and female adolescents positively
correlated with same sex parent on instruments measuring death anxiety. The
highest correlation coefficients were obtained between parents. These findings
suggest that cultural and societal influences may account for gender differences
on measures of death anxiety. Empirical investigations have indicated that
death anxiety is inversely related to income and educational level (Adaly, 1984;
Berman & Hayes, 1973; Cole, 1978; Kinlaw & Dixon, 1980; Schultz, 1978; Templer,
Barthlow, Halcomb, Ruff, & Ayers, 1979; Bolt, 1978).
Psychiatric patients and
persons who demonstrate significant levels of psychopathology exhibit elevated
levels of death anxiety (Templer, 1976). Templer (1970) administered the
Minnesota Multiphasic Personality Inventory (MMPI) to a psychiatric population
as part of the validation process of the Death Anxiety Scale (DAS). Highest
correlations with the DAS were on the Schizophrenia, Psychasthenia, and
Depression scales of the MMPI suggesting that schizophrenics,
obsessive-compulsives, and depressives experience elevated levels of death
anxiety. Death Anxiety is positively correlated with anxiety measured by
derived scales of the MMPI (Kuperman and Golden, 1978; and Gilliland,1982).
Measures of general anxiety and neuroticism, not associated with the MMPI, have
demonstrated a positive correlation with death anxiety (Lucas, 1974; Gilliland,
1982; Smith, 1977; Templer, 1972a). Depression is also positively correlated
with death anxiety (Templer, 1967, 1969, 1970; Ochs, 1979; Gilliland, 1982;
Koocher, O’Malley, Foster, and Gogan, 1976).
Death anxiety is
positively correlated with anxiety about the passage of time (Giroux, 1979;
Vargo and Batsel, 1981). Despite inconsistencies in research examining time
anxiety, Lonetto & Templer (1986, p. 22) report, “It has been hypothesized that
if the life review (no matter at what age it takes place) results in an
acceptance of one’s life along with a lack of guilt or concern about changing
it, than an individual can face mortality with little fear. In contrast,
despair, depression, dissatisfaction, fear of death, and a feeling that time is
running out will result if a life review concludes that one’s life has not been
a success.” An examination of death anxiety and existential adjustment
variables reveal an inverse relationship between variables of life satisfaction,
self-actualization and death anxiety (Wesch, 1971; Pollak, 1977; Tate, 1980;
Flint, Gayton, and Ozmon, 1983).
Research on the relationship between terminal illness and death
anxiety has been contradictory to what “commonsense” would dictate. Past death
anxiety literature has failed to demonstrate a strong negative relationship
between death anxiety and medical debilitation. Terminal cancer patients
demonstrated lower Death Anxiety Scale scores than control persons (Dougherty,
Templer, & Brown, 1986; Gibbs & Achterberg-Lewis, 1978). Average Death Anxiety
Scale scores were reported with kidney dialysis patients (Blakely, 1975; Lucas,
1974). Below average death anxiety has been reported with patients with
Huntington’s chorea (Gielen & Roche, 1979-1980). Most studies with the elderly
have not produced significant relationship between death anxiety and health
problems (Myska & Pasework, 1978; Templer, 1971a; Neustadt, 1982).
Lonetto & Templer (1986)
have suggested differential treatment for death anxiety based on the Two-Factor
Model:
If strong death anxiety is primarily a concomitant of a more
pervasive psychopathological condition such as a depression, an anxiety
neurosis, obsessive-compulsive neurosis or schizophrenia, then the underlying
syndrome should be treated symptomatically by psychotherapy, behavior therapy,
drugs, or electroconvulsive therapy. However, if strong death anxiety is a
relatively isolated symptom in a person who is otherwise psychologically healthy
and if such death anxiety is a product of unfavorable environmental experiences,
then death anxiety should be directly reduced by such behavior therapy
techniques as desensitization. For many men and women, strong death anxiety is
the product of more general psychopathology and specific death-related
experiences. In this case, death anxiety should probably be treated by some
combination of indirect and direct methods. (Lonetto & Templer, 1986, p. 79)
Death
education and workshops have been used to treat death anxiety in social work
students, nurses, physicians, ward medics, laboratory technicians,
psychologists, and college and high school students (Kirby & Templer, 1975;
Murray, 1974; Lockard, 1982; Polderman, 1976; Bailis & Kennedy, 1977; Edwards,
1983; Laube, 1977; McClam, 1980b; Whelan and Warren, 1980; Thomas, 1978;
Wittmaier, 1979). Death education involved didactic methods such as lectures,
discussions, and audiovisual teaching and experiential methods such as Berman’s
(1972) Death Awareness Exercises (e.g. participants imagine that they only have
24 hours in which to live and discuss with group members how they would spend
the day). Results of death education and workshops on death anxiety have
produced no significant changes, delayed effects, and in some studies, an
increase in death anxiety. The literature suggests that didactic approaches
increase defenses against death anxiety resulting in an increase in
symptomatology in some cases. Experiential approaches tend to decrease the fear
of dying due to the intense personal experiences that inhibit avoidance and
allow for new information to augment previous fears (Lonetto and Templer, 1986).
Behavioral
techniques, such as implosion, systematic desensitization, in vivo and imaginal
desensitization, and relaxation training, have been used for the treatment of
death anxiety in university students, nurses, and other health professionals
(Harlow, 1976; Bohart & Bergland, 1979; Testa, 1981). Results of these studies
indicate that desensitization procedures provided only moderate decreases in
death anxiety. Most of these studies recruited subjects who did not exhibit
high baseline levels of death anxiety resulting in a serious methodological flaw
in this area of death anxiety research. Interestingly, none of the studies
employing desensitization and implosive techniques recruited subjects who were
faced with imminent death or were terminally ill. Lonetto and Templer (1986)
suggest that desensitization techniques will be more effective when high death
anxiety results from personal experiences pertaining to the matter of death and
that further research is needed in this area. Perhaps direct and personal
experience is required to sufficiently activate the fear structure as it
pertains to death and dying before exposure and desensitization procedures can
commence as suggested in the behavioral treatment of phobias, trauma and
obsessive compulsive disorder utilizing prolonged exposure (Foa, Steketee,
Ozarow, 1985; Foa and Kozak, 1985, 1986; Barlow, 1994).
Near Death Experiences
(NDE) have been described as an out-of-body experience, where a person can see
and feel themselves outside of their own body that occur when one is close to
death (Lonetto & Templer, 1986). Approximately one third of people who come
close to death experience a NDE (Gallup & Proctor, 1982; Greyson & Stevenson,
1980; Sabom & Kreutzinger, 1977). Lonetto and Templer (1986) suggest that the
most important aspect of NDE’s is the displacement and slowing down of personal
time that is reported by a preponderance of people who experience NDE’s. The
majority people who experience NDE’s report positive effects. Attitude changes
and a reduction in the fear of death after NDE’s have resulted in the increase
of emotional health (Noyes, 1980). These changes incorporated both theistic
issues and a reassessment of priorities and awareness of life resulting in an
increase of meaningfulness. People who were close to death but did not
experience a NDE failed to report significant decreases in death anxiety when
compared to NDEers (Ring, 1980; Sabom, 1982). Perhaps NDE’s function as an
extreme method of implosion that activate and then modify the existing fear
structure resulting in the emotional processing and habituation of reactions
(e.g. irrational beliefs, avoidance) previously responsible for maintaining the
fear of death. The integration of new corrective information such as the
positive acceptance of death and the reduction of anxiety from not accomplishing
unmet goals may subsequently increase emotional health. Perhaps the lack of
emotional change in people who were close to death but did not experience NDE’s
were not exposed for a sufficient amount or did not spend enough time for
habituation and emotional processing to occur. Foa and Kozak (1986) suggest
that more intense and pervasive fears require longer exposure times to achieve
habituation. A substantial amount of time would probably be required for
habituation to occur for the fear of death.
Adult Emotional Functioning and Death
Anxiety in the HIV Population
Mental health professionals have
increasingly found themselves working with persons and families affected by the
AIDS virus. Anxiety and depression are the most frequently identified
psychological symptoms reported by persons with HIV (Kalichman & Sikkema,
1994). Empirical evidence has shown that the HIV population as a whole suffer
from a high level of subjective distress such as anxiety, fear, depression,
hopelessness, suicidal ideation, and guilt (Baer & Lewitter, 1989; Berube, 1989;
Dilley, Pies, & Helquist, 1989; Kooner et al., 1989, Hintze et al. 1993).
A review of the
literature demonstrates frequent contradictions in the severity of emotional
disturbances in subjects at different stages of HIV illness. Many studies
examining psychological disturbances in the HIV population have failed to both
utilize appropriate controls and classify symptomatic patients by severity of
illness (Green and Hedge, 1991).
Ostrow, Joseph,
Kessler, Soucy, Tal, Eller, Chmiel, and Phair (1989) reported that people who
engaged in high risk behaviors experienced few changes in emotional functioning
while individuals who engaged in low-risk behaviors experienced a decline in
mental health. Perry, Jacobsberg, Fishman, Frankes, Bobo, and Jacobsberg
(1990a) reported that both seropositive and seronegative participants
demonstrated high levels of psychological disturbances prior to notification of
HIV status. After receiving their results, the seronegative population
experienced a decrease of symptomatology but the seropositive group remained at
high elevations of emotional distress when measured 10 weeks after
notification. In contrast to these findings, Jadresic, Ricco, Hawkins, Wilson,
and Thompson (1994) reported that subjects testing positive initially reported
increased psychopathology but experienced a significant reduction of symptoms
after six months.
Chuang, Devins,
Hunsley, and Gill (1989) found that ARC and asymptomatic patients experienced
greater psychological disturbances than patients diagnosed with AIDS, with all
groups demonstrating increased psychopathology, but did not utilize seronegative
controls. Studies by King (1989) and Tross, Holland, Hirsch, Schiffman, Gold,
and Safai (1987) are ridden with pervasive methodological flaws (atypical
patient populations, no informed consent, long-standing psychiatric
disturbances).
Kurdek and Siesky
(1990) was the first study to utilize seronegative controls, reporting that
asymptomatic subjects demonstrated worse psychological functioning when compared
to symptomatic and seronegative controls. These asymptomatic subjects reported
greater death anxiety, psychological distress and lower optimism despite the
worse health profile exhibited by the symptomatic group. Data from symptomatic
patients in this study were analyzed as a whole and were not classified into
AIDS of ARC. This study also utilized a small sample size. Both of these
critiques of the methodology limit the power of these findings.
Kalichman and
Sikkema (1994) in a review of empirical findings reported that psychopathology
is routinely observed in the HIV population but that the prevalence and severity
is speculative due to methodological flaws such as pre-existing psychopathology
and sampling bias. It is not surprising that these studies on psychopathology
are contradictory with some studies reporting that 65% of people with AIDS met
diagnostic criteria for recurrent major depression (Atikinson, Grant, Kennedy,
Richman, Spector, McCutchan, 1988) and other studies reporting only 24% (Rabkin,
Williams, Neugebauer, Remein, and Goetz, 1990) and 12% (Kessler, O’Brien,
Joseph, Ostrow, Phair, Chmiel, Wortman, and Emmons, 1988).
Research on death
anxiety in the HIV population suffers from severe methodological flaws. Franks,
Templer, Cappelletty, & Kauffman (1987) studied males afflicted with AIDS, and
found greater death anxiety among persons with AIDS when compared to HIV
negative controls. ARC and asymptomatic patients were not represented in this
study. Hintze, Templer, Cappelletty, and Frederick (1993) reported positive
correlations of seriousness of medical and HIV status with death anxiety and
death depression but did not utilize healthy controls. Findings from this study
are not congruent with past death anxiety literature which does not support a
positive relationship between somatic integrity and emotional functioning.
Results from a pilot study conducted by Hayslip, Luhr, and Beyerlein (1991)
could not differentiate men with AIDS and those who were healthy using the
Templer Death Anxiety Scale, but found higher total scores for males with AIDS
than controls on the Incomplete Sentence Blank task. Asymptomatic and ARC
groups were not included in this study. Catania, Turner, Choi, and Coates
(1992) reported that HIV positive symptomatic men exhibited significantly higher
levels of death anxiety than both asymptomatic and HIV negative participants.
This study also combined ARC and AIDS participants into one group. Perhaps the
combination of these diagnoses is responsible for the inconsistent findings of
past literature.
Elevated rates of
panic, obsessive-compulsive (body-scanning compulsions), and generalized anxiety
disorders in the HIV-infected population have been reported (Triesman, 1994).
Rumination concerning physical appearance (Miller, 1990), compulsive checking
for new signs of disease progression (Maj, 1990; Ostrow, 1990), excessive
vigilance and exaggerated reactions to harmless bodily signs are widely observed
(Kessler et al., 1988).
Thomason et al.
(1996) emphasized the role of dysfunctional cognitions that characterize
psychopathology in the HIV and AIDS population. These researchers indicate that
feelings of worthlessness, excessive guilt and rumination over past behavior are
frequently reported. Triesman, Fishman, & Lyketsos (1994) reported that lack of
hope in finding a cure and feelings of helplessness in coping with the disease
are the predominant self-defeating thought patterns reported by HIV-positive
individuals (Triesman, Fishman, & Lyketsos, 1994). Forstein (1992) reported
that suicidal ideation may be higher in the HIV population when compared to
other chronic illness populations. Marzuk, Tierney, Tardiff, Morgan, Hsu, &
Marin (1988) reported that the risk of suicide among persons infected with HIV
may be up to 66 times greater than that of the general population.
Kalichman and
Sikkema (1994) suggest that the difficulty in estimating levels of psychological
distress and maladjustment prior to HIV infection is an inherited methodological
flaw in prior research. Populations that are more at risk for infection may
have higher pre-existing levels of psychological distress and subsequently have
a greater propensity for psychopathology upon notification of HIV status. The
majority of studies investigating psychological distress in the HIV population
tend to oversample men contracting HIV through homosexual contact, and who are
Caucasian, well educated, and of middle income, further contributing to the
difficulty for generalizing findings to other infected populations. Cohort
effects resulting from social support, multiple losses, prejudice, unemployment,
interpersonal conflicts, and religiosity provide researchers with additional
confounds when measuring the prevalence of psychopathology in this population.
The overlap between neurological, somatic, and vegetative symptoms of AIDS and
symptoms defining various depression disorders poses a problem when assessing
the accuracy of diagnosis of depression (Belkin, Fleishman, Stein, Peitte, and
Mor,1992; Drebring, Van Gorp, Hinkin, Miller, Satz, Kim, Holston, and D’Elia,
1994; Ostrow, 1990). Some studies have attempted to control for this overlap by
eliminating questions from self-report instruments and structured clinical
interviews. The use of multiple regression techniques to partial out
confounding somatic and neurological symptoms have also been implemented to
control for these confounds. Perhaps comparison groups, and screening
techniques could also control for cohort effects.
Review of Psychological Treatment for HIV/AIDS
and
Implications for Psychoimmunology
Cognitive
interventions are currently utilized in behavioral medicine for the treatment of
cardiovascular disorders, obesity, bulimia, chronic pain, benign headaches,
asthma, cancer, and AIDS/HIV (Emmelkamp & Oppen, 1993; Cottraux 1993).
Behavioral techniques, such as biofeedback and relaxation, have successfully
reduced blood pressure in various studies. Emmelkamp & Oppen (1993) and
Cottraux (1993) reported that cognitive-behavioral programs have successfully
augmented Type A behavior (behavior that is believed to increase a person’s risk
for heart disease) resulting in coronary changes. Research investigating the
utility of cognitive-behavioral therapy for the treatment for chronic pain has
been favorable (Emmelkamp & Oppen, 1993; Cottraux 1993). The reduction of pain
utilizing cognitive-behavioral therapy has been empirically supported for
lower-back pain, and vascular and tension headaches. Cognitive-behavioral
therapy focuses on altering the subjective experience of pain and increases a
patient’s capacity to utilize cognitive and behavioral coping techniques while
experiencing pain.
Cognitive-behavioral therapy has been utilized to manage aversive reactions to
chemotherapy and reduce emotional distress in cancer patients. Fawzy, Kemeny,
Fawzy, Elashoff, Morton, Cousins, and Fahey, (1990) has provided evidence that
cognitive-behavioral interventions improve immune functioning. Emmelkamp &
Oppen (1993) and Cottraux (1993) have stressed the need for further studies that
investigate the affect of cognitive-behavioral treatment on immunosuppression.
Research pertaining to the use of cognitive-behavioral therapy for helping
patients cope with death has not yet been investigated (Emmelkamp & Oppen, 1993;
Cottraux ,1993).
Emmelkamp & Oppen
(1993) and Cottraux (1993) suggest that psychosocial factors may affect the rate
and degree of immunosuppression. Reduction of emotional distress and the
greater capacity to cope with aversive life events may improve immune
functioning. The number of CD4 and natural killer cells are linked with immune
functioning and the progression of HIV and AIDS. Evidence from various studies
have indicated significant increases in CD4 cells and natural killer cells,
reductions in affective distress, and the reduction of disease symptoms after
receiving cognitive-behavioral, experiential, and supportive group therapy when
compared to controls (Antoni, August, LaPerriere, Baggett, Klimas, Ironson,
Schneiderman, Fletcher, 1990, 1991; LaPerriere, Antoni, Schneiderman, Ironson,
Klimas, Caralis, Fletcher, 1990; Mulder, Antoni, Emmelkamp, Veugelers,
Sandfort, van de Vijver, de Vries, 1995; Kelly, Murphy, Bahr, Kalichman, Morgan,
Stevenson, Koob, Brasfield, Bernstein, 1993). Taylor (1995) suggests that if
psychological stress can compromise immune functioning, psychological
interventions should be focused on increasing nervous system relaxation to
reduce anxiety. Cognitive restructuring and information on the psychological,
social, and physiological aspects of stress responses were utilized by various
studies as part of cognitive-behavioral treatment manuals to reduce stress and
improve immune functioning in the HIV population (Antoni et al., 1990, 1991;
LaPerriere et al., 1990; Mulder et al., 1995; Kelly et al., 1993; Taylor,
1995). Behavior change strategies such as assertiveness skills training,
increasing daily exercise, training in meditation and self-hypnosis, and
practicing muscle relaxation exercises were also included in these treatment
programs.
Kelly et al. (1993)
reported that HIV seropositive males experienced a decline in measures of
emotional distress after receiving either cognitive-behavioral or social support
group psychotherapy than a comparison group. Specifically, measures of
depression, anxiety, hostility, somatic preoccupation, and overall psychiatric
distress symptoms were specifically lower in the treatment groups. Kelly et al.
(1993) acknowledged a significant limitation of this study: participants with
more advanced stages of the disease were underrepresented, with fifty-six of the
sixty-eight men in this study asymptomatic at the commencement of the study. Of
these sixty-eight participants, five participants died, and 15% of the
participants with an AIDS diagnosis at the commencement of the study became too
ill to complete follow-up measures. This obvious subject bias makes it
difficult to generalize these findings to the heterogeneous HIV population at
large.
Taylor (1995)
conducted a study with five asymptomatic HIV-positive men who received
progressive muscle relaxation training, electromyograph biofeedback, meditation
and hypnotic training biweekly for ten weeks. Results of this intervention were
compared with a control group of five subjects who received no treatment but
were monitored in the same fashion as the treatment group. The author reported
that the intervention group exhibited significant clinical improvement from
pretreatment to posttreatment than a control group on measures of state anxiety,
trait anxiety, overall mood, self-esteem, and T-cell count. Despite the
relative small sample size, Taylor (1995) reports that his study provides
evidence that behavioral stress-management techniques may prove useful for
decreasing and managing stress in the HIV population with further implications
for the improvement of immune functioning.
Mulder et al.
(1994,1995) measured both the decline and increases of immunologic patterns in
39 homosexual male HIV seropositive asymptomatic patients who received
psychological interventions and a natural history control group over a two year
period. The psychological interventions utilized in this study were seventeen
2.5-hour sessions of cognitive-behavioral and experiential group therapy that
lasted for 15 weeks. Results from these studies suggested that there were no
significant differences between the two interventions on measures of affective
states but there were significant decreases in psychological distress when
controlled to a wait list control group. Significant changes in coping, social
support and emotional expression were found between treatment groups and the
wait list control groups. Mulder et al. (1994) hypothesized that significant
differences between treatment groups were not found due to a small sample size
and low pre-intervention distress levels which created a floor effect.
Mulder et al.
(1994,1995) found no changes in the rate of decline of CD4 cell count between
either therapy groups. Participants who experienced the greatest reduction of
emotional distress in both groups demonstrated the smaller decline in CD4
cells. The authors of this study report that methodological flaws, such as a
self-selected comparison group that was not randomly assigned and small sample
size, may have confounded the results despite the lack of significant
differences between these groups on demographic variables.
In contrast to the
previous findings, Coates, McKusick, Kung, and Stites (1989) reported only an
improvement in psychological distress with no significant changes in immune
number or function after HIV seropositive asymptomatic males received eight
weeks of stress reduction training. The protocol for stress reduction training
included systematic relaxation, changing health habits (behavioral contracts
concerning diet, rest, exercise, drug and alcohol use, and smoking), and
learning methods for managing the stress resulting from knowledge of HIV
status.
The Theory and General Principles of Rational
Emotive Behavior Therapy
Rational
Emotive Behavior Theory (REBT) suggests that emotions are most affected by
cognition. Events and individuals do not cause emotional disturbances
directly. Dysfunctional and irrational thinking is the most important
determinant of emotional distress. Rational Emotive Behavior Theory is based on
the assumption that the changing and modifying of dysfunctional thought
processes is essential to the alleviation of emotional disturbances. Ellis
(1976a, 1985) believes that human beings have a natural tendency to think
irrationally. Genetic and environmental influences predispose people to develop
and maintain irrational thinking, subsequently producing psychopathology.
“Like many
contemporary psychological theories, rational-emotive theory emphasizes present
rather than historical influences on behavior (Walen et. al, p.16, 1988).”
Ellis (1994) proposes that irrational beliefs can originate both during
childhood and throughout the course of a person’s life. Acquiring only an
understanding of the origins of your irrational beliefs is insufficient for
cognitive and affective change. Active and continuous effort is needed to
augment beliefs as well as styles of thinking. Despite the influence of
genetics and the environment, people maintain their disturbances and can
actively choose to adhere to or abandon certain patterns of thinking that
creates emotional distress.
Emotions can
originate from several pathways: the sensorimotor processes, biophysical
stimulation, cognitive processes, and from the experiencing of previous
emotional processes (Ellis, 1994). These main pathways interact and affect each
other to intensify emotional experience. REBT is a means of influencing emotion
by augmenting evaluations and beliefs through the use of the cognitive pathway.
Ellis (1994) suggests that most emotional experiences are derived from
appraisals of reality and affect the other three pathways for the stimulation of
emotion. Appraisals or thinking is personalized and biased, is usually
accompanied by bodily reactions, stimulates emotion and subsequently influences
behavior. Sustained emotions are the result of repeated ideas and appraisals.
REBT
considers evaluative beliefs rather than inferential beliefs to be most
important in the development and maintenance of psychopathology (Ellis,
1994,Walen et. al, 1992). Inferential beliefs are the inferences that are
formed from perceptions of reality. Assumptions are typically created during
interpersonal exchanges. The cognition that develops from our assumptions of
reality are automatic and can be both correct and incorrect. People who extract
a preponderance of faulty assumptions from reality experience deleterious
effects on their affective functioning. Perception and ways of responding are
both utilized during the evaluation process. Ellis (1994) suggests that people
emote when they evaluate something strongly and can be viewed as both positive
and negative.
Ellis (1962)
originally emphasized the importance of self-talk and internalized sentences in
the experience of emotion. Currently, Ellis (1994) believes that self-talk and
internalized sentences are responsible for only a portion of human emotion and
that core philosophies and underlying evaluative beliefs are primarily
responsible. The appraisal of the truth, or in other words, your belief about
the truth is the focus of REBT. Evaluative beliefs, known as core Irrational
Beliefs in REBT theory, can be divided into four categories: demands,
awfulizing, low frustration tolerance, and global evaluations of human worth.
Burgess (1990)
describes a recent shift in rational emotive theory from eleven irrational
beliefs (Ellis, 1962) to one superordinate irrational belief referred to as
absolutistic thinking, or demandingness (Ellis, 1989, 1987, 1984, 1994; Ellis
and Dryden, 1987). Ellis believes that demandingness is the cause of and is
present in all psychopathology. “Demands reflect unrealistic and absolute
expectations of events or individuals, and are often recognizable by cue words
such as must, ought, should, have to, and need (Walen et. al, 1992, p. 17).”
Ellis (1994) suggests that three main categories of demands: self-demandingness,
other-demandingness, and world-demandingness, comprise the majority of
irrational beliefs. Ellis has proposed three subordinate derivatives of
demandingness: awfulization, low frustration tolerance, and worthlessness.
Awfulizing is a way of exaggerating the negative consequences of a situation to
an extreme degree, so that an unfortunate occurrence becomes “terrible.” Low
frustration tolerance stems from demands for ease and comfort, and reflects an
intolerance of discomfort. Global evaluations of human worth, either or the
self or others, imply that human beings can be rated, and that some people are
worthless, or at least less valuable than others. (Walen, 1992, p. 17)
The ABC’s of Rational Emotive Behavior Therapy
Ellis
constructed a simple model to facilitate the understanding of the interactions
between Activating Events (A’s) Beliefs (B’s) and emotional, behavioral, and
physiological Consequences (C’s). People are driven by Goals (G’s) which
include survival, the avoidance of pain, and the striving for satisfaction.
Goals influence the way people perceive events and evaluate reality. Activating
Events (A’s) can be both confirmable and perceived. Confirmable activating
events (A’s) can be confirmed by other people. Perceived activating events
(A’s) are a person’s subjective experience and description of reality. People
interpret A’s based on their G’s using their Belief System (B), evaluating what
they perceive. Two kinds of Beliefs, Rational Beliefs (RB’s) and Irrational
Beliefs (IB’s), evaluate reality and are influenced by Goals (G’s). All people
have both types of beliefs. Rational Beliefs are responsible for healthy
emotional and behavioral consequences (C’s). Irrational Beliefs (IB’s) create
emotional disturbances and influence dysfunctional behavior (C’s). The goal of
REBT is to help patients differentiate between these types of beliefs so that
they can challenge and replace irrational beliefs (IB’s) with more rational
beliefs (RB’s) to alleviate emotional distress and negative consequences (C’s).
Rational
Beliefs are logical and verifiable (Walen et. al, 1992; Ellis, 1994). Rational
Beliefs are not demanding and result in adaptive emotions. They assist in
helping people achieve goals and maximize satisfaction. In contrast, Irrational
Beliefs are illogical and inaccurate. Irrational Beliefs are dogmatic,
inconsistent with reality, exaggerated, lead to disturbed emotions, and hinder
the achievement of goals. A comprehensive list of the eleven Irrational Beliefs
conceptualized by Ellis (1962, 1994) details the extent of irrationality across
various areas of human functioning.
REBT also
focuses on a person’s ability to disturb themselves about their disturbances.
Patients typically view themselves as behaving poorly when they are emotionally
disturbed and subsequently become disturbed about their disturbances. Emotions
and behavior that are considered Consequences (C’s) become new Activating Events
(A’s). Patients become anxious about their anxiety, depressed about their
depression, and angry about their anger. A patient’s ability to upset
themselves in this way have been classified by Ellis as secondary emotional
disturbances (Ellis, 1994).
Disputing (D)
the validity of Irrational Beliefs (IB’s) is the primary method of alleviating
emotional distress. Patients can then generate new, more functional Effective
Rational Beliefs (ERB’s) to replace past IB’s. Disputing (D) can be conducted
cognitively through the scientific questioning and challenging of absolutistic
and demanding beliefs. Disputing can also be performed emotively and
behaviorally utilizing several methods such as imagery, shame-attacking
exercises, role-playing, forceful coping statements, forceful disputing, and
humor. Behavioral methods including in vivo exposure, systematic
desensitization, reinforcement, penalties, and assertiveness training are also
used to directly elicit emotion.
The Relationship
Between Neuroticism, Anxiety, Depression, and Irrational beliefs
Past investigations
have examined the relationship between neuroticism, state-trait anxiety,
depression, emotionality, extraversion and irrational beliefs. Eysenck and
Eysenck (1975) have proposed that neuroticism is linked theoretically to
emotional maladjustment. Ellis and Harper (1975) have suggested that irrational
beliefs are responsible for maladjustment.
Warren and
Zgourides (1989, 1988) have suggested that a positive correlation exists between
irrational beliefs, anxiety, and depression. Anxiety is the result of
future-oriented cognition (Walen, et al., 1992). Situations in the here-and-now
rarely illicit excessive anxiety. Catastrophizing and awfulizing are common
irrational beliefs that cause anxiety. The fear of rejection, the fear of
failure, and the fear of being afraid are the most common fears. Depression can
be identified as a negative view of the self, a negative view of the world, and
a negative view of the future (Beck, 1976). The irrational structures of
self-blame, self-pity, and other-pity cause depression.
Morelli and Andrews
(1980) have found a positive correlation between irrational beliefs,
neuroticism, and extraversion. Irrational beliefs were strongly related to test
anxiety and trait anxiety (Rohsenow and Smith, 1982). Type A behavior has been
shown to be related to irrational beliefs reflecting an inordinate need for
competence and concern about control issues (Hamberger and Hastings, 1986).
Irrational beliefs were also found to be related to negative emotionality
(Nottingham, 1992). Measures of irrational beliefs correlate more highly with
each other than with accepted measures of depression, hopelessness, and anxiety,
suggesting that instruments used to detect irrational beliefs do not just
measure general distress or emotionality (Nottingham, 1992).
Emotional
Disturbances in the HIV/AIDS Population:
The Need for A
Rational Emotive Behavioral Approach for Treatment
Cognitive
behavioral therapists, who historically have relied on empirically based
interventions to treat anxiety and depressive disorders (Beck, 1976; Beck et al.
1979, 1985; Ellis, 1962, 1994), have the opportunity to help HIV and AIDS
patients. The enhancement of coping skills, adapting to changing medical status
and physical limitations, providing a perspective on living with a chronic and
debilitating disease, and maintaining supportive relationships are issues that
cognitive-behavioral therapists can help facilitate (Thomason et al. 1996).
Cognitive
restructuring methods utilized in past HIV studies (Antoni et al., 1990, 1991;
LaPerriere et al., 1990; Mulder et al., 1995; Kelly et al., 1993; Taylor, 1995)
primary utilized Cognitive Therapy (CT) and restructuring techniques (Beck,
1976; Beck and Emery, 1985) that focused primarily on inferential beliefs.
Techniques proposed by REBT, which focus on more philosophic and evaluative
changes, may provide patients with greater and more lasting changes in emotional
functioning.
Behavioral
interventions such as in vivo desensitization, flooding, implosion, and imaginal
exposure focusing specifically on fear reduction of existential aspects
associated with disease progression have not been empirically validated for the
HIV population. A recent literature review by Thomason, Bachanas, and Campos
(1996, p. 431) brings to the forefront this need for future research, “For
example, we might speculate that an inordinate fear of death or an obsession
with thoughts of dying might be amenable to exposure-based treatments or
desensitization techniques. To our knowledge, no reports exist in the
HIV-related literature to address this contention.”
To date, empirical
investigations involving irrational beliefs (as defined by Rational Emotive
theory) or Rational Emotive Behavioral Therapy (REBT) with the HIV or AIDS
population have not been conducted. Bernard (1995) states the need for “the
incorporation of Rational Emotive Behavioral Therapy in comprehensive treatment
programs for modern and future-day problems such as AIDS, victim abuse, and
criminal behavior.”
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