An Investigation of Irrational Beliefs and Death Anxiety as a Function of HIV Status

Jeffrey W. Braunstein
California School of Professional Psychology, Fresno Campus

Abstract

The present study investigated the relationship of irrational beliefs and death anxiety as a function of Human Immunodeficiency Virus (HIV) status in homosexual and bisexual men.  101 HIV-seropositive participants (34 asymptomatic, 30 symptomatic and 37 symptomatic and diagnosed with AIDS) and a contrast group (40 HIV-seronegative) were recruited for this study.  In the primary analysis, HIV negative participants in this study could not be differentiated from asymptomatic, symptomatic and AIDS diagnosed HIV infected participants on measures of death anxiety and irrational beliefs regardless of the status or severity of illness.  In addition, irrational beliefs strongly predicted death anxiety for all participants.  Results from post-hoc analyses suggested that HIV status produced an interaction effect with level of total irrational beliefs and together predicted death anxiety.  Even in these analyses, total irrational beliefs explained more of the variance of death anxiety than HIV status. These results are discussed within the context of the need for expanding cognitive-behavioral treatment options for HIV infected individuals.

An Investigation of Irrational Beliefs and Death Anxiety as a Function of HIV Status

            An estimated 40 million people are living with the HIV infection worldwide (Joint United Nations Programme on HIV/AIDS World Health Organization, 2001).  There were 5 million new HIV infections and 3 million deaths related to HIV infection in 2001 worldwide.  In the United States alone, 940,000 adults and children currently live with the HIV infection.  Over the past 20 years, mental health professionals have increasingly found themselves working with persons and families affected this disease.  Cognitive behavioral therapists have the opportunity to help HIV patients learn coping skills, accept physical limitations, and maintain supportive relationships to improve their quality of life (Thomason, Bachanas, & Campos, 1996).   

Emotional Disturbances in the HIV Population

            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 suffers 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; Hintze, Templer, Cappelletty, & Frederick, 1993; Kooner et al. 1989).

            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 utilize appropriate controls, classify symptomatic patients by severity of illness, and provide asymptomatic comparison groups (Green & Hedge, 1991).  The overlap between neurological, somatic, and vegetative symptoms of AIDS and symptoms defining various depressive disorders poses a problem when assessing the prevalence of depression (Belkin, Fleishman, Stein, Peitte, & Mor, 1992; Drebing et al. 1994; Ostrow, 1990).  A failure to control for pre-existing psychopathology, cohort effects, as well as sampling bias has further questioned the validity of past research exploring the emotional functioning of this population (Kalichman & Sikkema, 1994).

            Perry et al. (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, Riccio, Hawkins, & Wilson (1994) reported that subjects testing positive initially reported increased psychopathology but experienced a significant reduction of symptoms after six months.  Chuang, Devins, Hunsley, & Gill (1989) found that AIDS Related Complex (ARC) and asymptomatic patients experienced greater psychological disturbances than patients diagnosed with AIDS, with all group demonstrating increased psychopathology, but they did not utilize seronegative controls. 

Death Anxiety in the HIV Population

            The Two-Factor Model of Death Anxiety (Lester & Templer, 1993, Lonetto & Templer, 1986) 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 principals 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).  Death Anxiety appears to be positively correlated with general anxiety (Gilliland, 1982; Kuperman & Golden, 1978; Lucas, 1974; Smith, 1977).

            Past research has provided evidence for the existence of death anxiety in the HIV population but has demonstrated frequent contradictions in its severity at different stages of the illness (Catania, Turner, Choi, & Coates, 1992; Franks, Templer, Cappelletty, & Kauffman, 1990; Hayslip, Luhr, & Beyerlein, 1991; Hintze, Templer, Cappelletty, & Frederick, 1993).  Many of these results contradict past literature concerning the relationship between death anxiety and physical well being (Blakely, 1975; Dougherty, Templer, & Brown, 1986; Gibbs & Achterberg-Lewis, 1978; Gielen & Roche, 1979-1980; Lonetto & Templer, 1986; Lucas, 1974; Myska & Pasework, 1978; Neustadt, 1982; Templer, 1971).

            Franks et al. (1990) studied males afflicted with AIDS, and found greater death anxiety among person with AIDS when compared to HIV negative controls.  ARC and asymptomatic patients were not represented in this study.  Kurdek & Siesky (1990) were the first 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 or ARC groups and utilized a small sample size.

            Hintze et al. (1993) reported positive correlations of seriousness of medical and HIV status with death anxiety but did not utilize healthy controls.  Results from a pilot study conducted by Hayslip et al. (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 et al. (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.  These inconsistent findings within the death anxiety literature, investigating the relationship between somatic integrity and emotional functioning, could be due to the aforementioned methodological flaws.  Therefore, an investigation of death anxiety in the HIV population, with improved methodology and additional controls, may yield results more consistent with past death anxiety literature.

Dysfunctional Cognition in the HIV Population

            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.  Treisman, 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 (Treisman et al. 1994).  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.  Forstein (1992) reported that suicidal ideation might be higher in the HIV population when compared to other chronic illness populations.  Despite these aforementioned studies reviewing dysfunctional cognition, an investigation of irrational beliefs in the HIV population has not yet been conducted.

Rational Emotive Behavior Therapy: Theoretical Revisions

            Burgess (1990) describes a recent shift in rational emotive theory from eleven irrational beliefs to one superordinate irrational belief referred to as absolutistic thinking, or demandingness.  Ellis believes that demandingness is the cause of and is present in all psychopathology (Ellis, 1994, 1989; Ellis & Dryden, 1987).  Ellis has proposed three subordinate derivatives of demandingness: awfulization, low frustration tolerance, and worthlessness.

The Connection Between Irrational Beliefs and Anxiety

            Previous research has suggested that a positive correlation exists between irrational beliefs and anxiety and depression (Bernard, 1998; Warren & Zgourides, 1989).  Anxiety is the result of future-oriented cognition (Walen, DiGiuseppe, & Wessler, 1992).  Situations in the “here-and-now” rarely elicit excessive anxiety.  Catastrophizing and awfulizing are common irrational beliefs that cause anxiety.  Fears of rejection, failure, and the fear of being afraid are the most common fears associated with anxiety.

            Morelli & Andrews (1980) have found a positive correlation between irrational beliefs and neuroticism and extraversion.  Irrational beliefs were strongly related to test anxiety and trait anxiety (Rohsenow & Smith, 1982) and to the fear of flying (Moller, Nortje, & Helders, 1998).  Type A behavior has been shown to be related to irrational beliefs reflecting an inordinate need for competence and concern about control issues (Hamberger & 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).

Current Study 

            The purpose of this study was to investigate the relationship of irrational beliefs and death anxiety as a function of Human Immunodeficiency Virus (HIV) status in homosexual and bisexual men.  To date, empirical investigations involving irrational beliefs or Rational Emotive Behavioral Therapy (REBT) with the HIV population have not been conducted.  This study utilized an instrument that measured only attitudes and beliefs (excluding references to emotional distress or behavioral consequences) and accounted for the revisions to REBT theory.  Furthermore, though the connection between irrational beliefs and anxiety has been well established, (Hamberger & Hastings, 1986; Morelli & Andrews, 1980; Rohsenow & Smith, 1982; Walen et al. 1992; Warren & Zgourides, 1989), the relationship between irrational beliefs and death anxiety has not been investigated.

            It was predicted that HIV positive asymptomatic and symptomatic groups will exhibit more death anxiety and total irrational beliefs than seronegative controls and participants with AIDS.  This hypothesis was based on previous literature on death anxiety and terminal illness (Blakely, 1975; Dougherty et al. 1986; Gibbs & Achterberg-Lewis, 1978; Gielen & Roche, 1979-1980; Lonetto & Templer, 1986; Lucas, 1974; Myska & Pasework, 1978; Neustadt, 1982; Templer, 1971).  Cognitive-behavioral theory (Ellis, 1994, 1989; Ellis & Dryden, 1987; Walen, et al. 1992), which claims that anxiety is the result of future-oriented cognition, also supports this prediction.

            It was hypothesized that irrational beliefs in general will be positively correlated with death anxiety.  In addition, it was hypothesized that the specific irrational belief demandingness will be correlated positively with death anxiety.  These hypotheses were based on literature demonstrating a positive correlation between irrational beliefs and generalized anxiety (Hamberger & Hastings, 1986; Morelli and Andrews, 1980; Nottingham, 1992; Rohsenow & Smith, 1982; Walen et al. 1992; Warren & Zgourides, 1989).  In addition, revisions in the REBT model of psychopathology, (Ellis, 1994, 1989; Ellis & Dryden, 1987), which suggests that demandingness is the superordinate irrational belief, supports these hypotheses.

Method

Participants

            The population for this study was limited to homosexual and bisexual adult men.  101 HIV-seropositive homosexual and bisexual men were recruited for this study.  The participants ranged in age from 19 to 54 years.  Of these 101 HIV-seropositive men, 34 were Asymptomatic, 30 were Symptomatic, and 37 were symptomatic and diagnosed with AIDS. 

Of the 34 Asymptomatic participants, 32 were homosexual and 2 were bisexual.  Their mean age was 35.4 yr. (SD = 8.3).  Regarding the ethnicity of this group, 21 were Euro-American, 6 were African-American, 6 were Hispanic, and 1 was Asian.  Six of these participants held a MA/MS degree, 10 completed a BA/BS degree, 7 held an AA/AS degree, 9 completed high school, and 2 did not complete high school.  Twenty- four (70%) of these participants were receiving medical treatment at the time of this study and 23 (67%) reported an improvement in their condition as result of treatment.  Only 8 (23.5%) were receiving mental health treatment and 6 (17%) of these participants were receiving psychiatric medication at the time of this study.

Of the 30 Symptomatic participants, 29 were homosexual and 1 was bisexual.  Their mean age was 38.1 yr. (SD = 7.3).  Regarding the ethnicity of this group, 19 were Euro-American, 4 were African-American, and 7 were Hispanic.  One of these participants was awarded a doctorate, 2 held a MA/MS degree, 3 completed a BA/BS degree, 6 held an AA/AS degree, 13 completed high school, and 5 did not complete high school.  Twenty-three (76.7%) of these participants were receiving medical treatment at the time of this study and 21 (70.0%) reported an improvement in their condition as result of treatment.  Seventeen (56.7%) were receiving mental health treatment and 13 (43.3%) of these participants were receiving psychiatric medication at the time of this study.

Of the 37 participants diagnosed with AIDS, 32 were homosexual and 5 were bisexual.  Their mean age was 39.9 yr. (SD = 5.1).  Regarding the ethnicity of this group, 21 were Euro-American, 7 were African-American, 5 were Hispanic, and 4 were classified as “other.”  Two of these participants held a MA/MS degree, 13 completed a BA/BS degree, 6 held an AA/AS degree, 11 completed high school, and 5 did not complete high school.  Thirty-four (91.9%) of these participants were receiving medical treatment at the time of this study and 31 (83.8%) reported an improvement in their condition as result of treatment.  Fifteen (40.5%) were receiving mental health treatment and 9 (24.3%) of these participants were receiving psychiatric medication at the time of this study.

A contrast group of 40 HIV-seronegative homosexual and bisexual men were recruited for this study.  These participants ranged in age from 24 to 73 years.   Thirty-one were homosexual and 9 were bisexual.  Their mean age was 38.0 yr. (SD = 10.8).  Regarding the ethnicity of this group, 29 were Euro-American, 5 were African-American, 3 were Hispanic, and 3 were classified as “other.”  Three of these participants were awarded a doctorate, 6 held a MA/MS degree, 14 completed a BA/BS degree, 9 held an AA/AS degree, 7 completed high school, and 1 did not complete high school.  Ten (25.0%) were receiving mental health treatment and 5 (12.5%) of these participants were receiving psychiatric medication at the time of this study.

Instruments

            Demographic Questionnaire.  All participants completed a two-page demographic questionnaire.  This brief self-report instrument identified the participant’s age, sexual orientation (homosexual or bisexual), ethnicity, education level, HIV status, current medication status for both HIV and mental illness, and improvement of condition due to advances in treatment.  The questionnaire identified when participants in the criterion group received initial notification of HIV status and route of infection.  The instrument also identified the participant’s history of mental health treatment and current relationship status. 

            Death Anxiety Scale (DAS).  The DAS (Templer 1970) is a 15-item forced choice questionnaire derived from an original set of 40 items.  Nine of the 15 items are keyed “true” and six are keyed “false.”  Templer (1970) reported that the scale survived both face validity and internal consistency analyses.  Test-retest reliability has been found to be .83 for college students.  A coefficient of .76 suggests satisfactory internal consistency with these participants.  Psychiatric patients who spontaneously verbalize death anxiety had higher DAS scores than other psychiatric patients.

            Attitudes and Belief Scale II (ABSII).  The ABSII is a measure of Ellis’ (1994) Irrational/Rational Beliefs (DiGiuseppe, Leaf, Robin, & Exner, 1988).  It consists of 72 items with three factors.  The first factor for Cognitive Process has four levels representing the irrational belief processes of Demandingness, Self-Worth, Low Frustration Tolerance, and Awfulizing.  The second factor, Content/Context has three levels: beliefs about Affiliation, Achievement, and Comfort.  The third factor has two levels: irrationality worded items and rationally worded items.  Items were selected for use in the scale only if there was unanimous agreement among 13 judges who were therapists at the Institute for Rational-Emotive Therapy (IRET).  The ABSII only measures attitudes and beliefs and does not include references to emotional distress or behavioral consequences, which may artificially increase correlational relationships.  Past measures of irrational beliefs have received significant criticism due to the aforementioned confound.

            The ABSII has demonstrated excellent internal consistency and validity (DiGiuseppe et al. 1988) with alpha coefficients ranging from .71 to .89 in a sample of 431 college students.  The ABSII has also demonstrated excellent internal consistency and validity in a sample of clinical and college student groups (N=1135) with alpha coefficients for the four belief processes and the three content subscales ranging from .92 to .86 (DiGiuseppe, Robin, Leaf, & Gormon, 1989).  The total score for the entire 72 items yielded an alpha coefficient of .96.  The ABSII can adequately discriminate between non-disturbed and disturbed groups, with the endorsement of rational items providing the best power to classify (DiGiuseppe et al. 1988, 1989). 

Procedure

            The principal investigator contacted medical centers, hospitals, hospices, newspapers, and various AIDS organizations to obtain permission to approach their clients or advertise for participants both for the control and criterion groups.  Advertisements for recruiting participants were placed in New York and California newspapers.  Flyers were made available for potential participants with the investigator’s phone number to arrange for receiving all materials.  The flyer also provided the names and addresses of agencies that provided materials anonymously.  Distribution of materials was conducted by the principal investigator and agency employees.  All participants received written instructions for completing all materials.  All participants were guaranteed anonymity and were instructed to sign consent before beginning other procedures.  Participants were instructed to not write their name on any of the materials with the exception of the consent form.  They were informed that the consent forms would be separated from all other materials.  Participants were instructed to mail the consent form separately from all other materials.  Two enclosed envelopes with pre-paid postage addressed to the principal investigator facilitated this process.  The participants were informed that they would receive five dollars for completing the instruments, with reimbursement sent to the address provided on the consent form.  Participants with a lifetime history of IV drug use were excluded to reduce possible confounding variables.  The estimated amount of time needed for the participants to complete all parts of the study was approximately 40 minutes.

Results

            Two, one-way ANOVAS were conducted to analyze death anxiety and total irrational beliefs as a function of HIV status.  Table 1 presents the means and standard deviations of the total scores on the Death Anxiety Scale and the Attitude and Belief Scale II (TOTABS).  There was no difference in death anxiety between the four HIV status groups, F(3, 137) = 1.02, p > .05.  The contrast comparing HIV negative and AIDS participants against asymptomatic and symptomatic participants revealed no difference in death anxiety among these two subsets, t(137) = 1.02, p > .05 (Refer to Table 2).  There was no difference in total irrational beliefs between the four HIV status groups, F(3,137) = 1.71, p > .05.  The contrast comparing HIV negative and AIDS participants against asymptomatic and symptomatic participants revealed no difference in total irrational beliefs among these two subsets, t(137) = 2.10, p > .05 (Refer to Table 2).

A post-hoc multiple regression was conducted to test whether HIV status, TOTABS, and the interaction of HIV status x TOTABS would predict death anxiety (see Table 3).  For this analysis, the three HIV positive groups (asymptomatic, symptomatic and AIDS diagnosis) were collapsed into one group (n = 101).  The regression model explained 14% of the total variance of death anxiety (R² = .14, p < .001).  HIV status explained four percent of the variance of death anxiety, t(140) = 2.65, p < .01.  TOTABS explained 10% of the variance of death anxiety, t(140) = 3.93, p < .001.  The interaction of HIV status x TOTABS explained 3% of the variance of death anxiety, t(140) = -2.29, p < .05. 

            To analyze within group differences, a median split procedure was initially conducted to classify participants in each HIV status group to either a “Low TOTABS” or “High TOTABS” group (TOTABS / HIV negative median = 72.5; TOTABS / HIV positive median = 86.0).  Table 4 presents the means and standard deviations on the Death Anxiety Scale for HIV negative and HIV positive participants by level of irrational belief.  A post-hoc one-way ANOVA was then conducted to analyze death anxiety as a function of low vs. high irrational beliefs (TOTABS) and HIV status (positive vs. negative) for these four groups (Refer to Table 5).  There was a significant difference in death anxiety between the four groups, F(3, 137) = 6.65, p < .001.  Post hoc tests measuring differences between the four groups were conducted demonstrating significant differences in death anxiety symptoms between Low TOTABS / HIV Negative and High TOTABS / HIV Negative groups (mean difference = -3.65, p < .001), Low TOTABS / HIV Negative and High TOTABS / HIV Positive groups (mean difference = -2.25, p < .01), Low TOTABS / HIV Negative and High TOTABS / HIV Positive groups (mean difference = -3.69, p < .001), and Low TOTABS / HIV Positive and High TOTABS / HIV Positive (mean difference = -1.44, p < .05).

A bivariate correlation analysis was conducted to examine the relationship between death anxiety and total irrational beliefs among all participants.  Using a Pearson Product Moment correlation coefficient with one-tailed significance, the data indicated a significant positive correlation between death anxiety and total irrational beliefs for the overall sample (N = 141), r = .31, p < .001.  Bivariate correlations were conducted between death anxiety and total irrational beliefs among participants as a function of dichotomous HIV status (HIV positive and HIV negative).  Using a Pearson Product Moment correlation coefficient with two-tailed significance, the data revealed no significant correlation between death anxiety and total irrational beliefs for the HIV positive group (n = 101), r = .18, p = .075.  In contrast to the HIV positive group, the data revealed a significant positive correlation between death anxiety and total irrational beliefs for the HIV negative group (n = 40), r = .55, p < .001.

Discussion

            In conclusion, these results support Ellis’ theory that irrational beliefs significantly contribute to the existence of death anxiety as a function of HIV status.  In the primary analysis, HIV negative participants in this study could not be differentiated from asymptomatic, symptomatic and AIDS diagnosed HIV infected participants on measures of death anxiety and irrational beliefs regardless of the status or severity of illness.  In addition, irrational beliefs strongly predicted death anxiety for all participants.  Results from post-hoc analyses suggested that HIV status, when collapsed into a dichotomous HIV negative / HIV positive variable, produced an interaction effect with level of total irrational beliefs, and together predicted death anxiety.  Even in these analyses, total irrational beliefs explained more of the variance of death anxiety than HIV status.  After sorting participants into “Low vs. High” total irrational belief groups and by dichotomous HIV status, significant within and between group differences were observed, providing further evidence for the interaction between the activating event (HIV status) and irrational beliefs.  This effect may be due to the higher level of death anxiety among the HIV positive participants versus the HIV negative participants at the level of low irrational beliefs.  Results from the post-hoc analyses must be interpreted with extreme caution due to the large discrepancy in sample size between the HIV negative group (n = 40) and the collapsed HIV positive group (n = 101).

            The findings in this study contradict previous HIV research on death anxiety and disease progression.  It was originally hypothesized that participants in the middle stages of the disease (Asymptomatic and Symptomatic) would experience a greater degree of fear, apprehension, and irrational belief due to the uncertain and unpredictable nature of disease progression.  This curvilinear relationship between death anxiety and irrational beliefs across HIV status, based on cognitive-behavioral theory claiming that anxiety resulted from future-oriented cognition, was unfounded.  Further research focusing on the sequence of irrational beliefs and their relationship to emotional disturbances would provide a more comprehensive understanding of the cognitive processes experienced by this population.

These findings have direct implications for psychological treatment.  Cognitive-behavioral interventions could prove effective in the treatment of death anxiety by increasing a patient’s capacity to tolerate future symptoms and by de-catastrophizing life and death issues.  Research pertaining to the use of cognitive-behavioral therapy for helping patients cope with death has not yet been investigated (Cottraux, 1993; Emmelkamp & Oppen, 1993; Thomason, et al. 1996).

            Future research could benefit from the improvement of several design and measurement limitations revealed in this study.  The use of multiple death anxiety and irrational belief measures would increase external validity and the generalizability of findings.  Since the level of death anxiety across all status groups was normative, death anxiety levels may not have been high enough for sufficiently differentiating HIV status and specific irrational beliefs.  Recent changes in disease progression may have instilled hope in persons infected with HIV and subsequently lowered the overall levels of death anxiety across all HIV infected status groups. Measuring emotional disturbances such as depression and anger may provide an adequate amount of the independent variable needed for rectifying these methodological concerns.

            Since illicit substances are often used to help people self-medicate emotional disturbances, an attempt to exclude participants who reported a history of IV drug use was made to help control for this possible confound.  Although the prevalence of IV drug use was assessed, other substance abuse and self-medicating issues were not controlled for in this study.  Future research should assess the prevalence of substance use and its impact on the experience of emotional disturbances in the HIV population.

Advances in the medical treatment of HIV have increased life expectancy and changed the course of the illness.  HIV infected individuals experience even greater fluctuations in their condition than in the past.  In the late 1990’s, many people diagnosed with AIDS experience fewer symptoms and resume levels of functioning similar to the Asymptomatic and Symptomatic period of illness.  These changes in disease progression challenge the current classification system currently used for diagnosing HIV status.  Perhaps the measurement of current symptoms, viral load, and number of hospitalizations for disease related illnesses, can provide a more accurate diagnosis of disease progression and HIV status.

            With the rapid increase in HIV patients seeking mental health treatment, REBT has the potential for effectively treating the emotional disturbances experienced by this population.  It is imperative for REBT therapists to continue the expansion of treatment options.  The development of a cognitive-behavioral treatment protocol would provide both effective treatment and research in an area of study that is still in its infancy.  An REBT treatment protocol would improve on previous cognitive-behavioral attempts that focused solely on inferentially based cognition.  Future cognitive-behavioral HIV research should continue the investigation into the nature and prevalence of irrational beliefs and their subsequent emotional disturbances.

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Joint United Nations Programme on HIV/AIDS (UNAIDS, 2001) World Health Organization (WHO).Table 1

Means and Standard Deviations for the Total Scores on the Death Anxiety Scale and Attitude and Belief Scale II for HIV Status Groups

Note.  DAS = Total Score Death Anxiety Scale; TOTABS = Total Score Attitude and Belief Scale II.

Table 2

One-Way Analysis of Variance with Contrasts of Total Scores on the Death Anxiety Scale and Attitude and Belief Scale II by HIV Status

Note.  Four group HIV status: HIV negative (n = 40), HIV asymptomatic (n = 34),

HIV symptomatic (n = 30), and AIDS diagnosis (n = 37).

Table 3

Summary of Post-hoc Regression Analysis for Variables Predicting Death Anxiety

Note.  Two group HIV status: HIV positive (n = 101) and HIV negative (n = 40). 

TOTABS = Total Score Attitude and Belief Scale II.

*p < .05.  **p < .01.  ***p < .001.

Table 4

Means and Standard Deviations of Death Anxiety for HIV Negative and HIV Positive Participants by Level of Irrational Belief

Note.  TOTABS = Total Score Attitude and Belief Scale II.

Four group HIV status: Low TOTABS / HIV negative (n = 20), High TOTABS / HIV negative (n = 20), Low TOTABS / HIV positive (n = 50), and High TOTABS / HIV positive (n = 51).  Level of irrational belief determined by median split scores.

Table 5

Post-hoc One-Way Analysis of Variance of Death Anxiety by Level of Irrational Belief and HIV Status

Note.  Four group HIV status: Low TOTABS / HIV negative (n = 20), High TOTABS / HIV negative (n = 20), Low TOTABS / HIV positive (n = 50), and High TOTABS / HIV positive (n = 51).  Level of irrational belief determined by median split scores.

***p < .001

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