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Death Anxiety in the HIV Population:
Implications for Exposure-based Interventions
Jeffrey W. Braunstein, Sai Q. Lee, and Valerie
E. Forward
California School
of Professional Psychology, Fresno
Abstract
At the present time,
only behavior change strategies such as assertiveness skills training,
increasing daily exercise, meditation, progressive muscle relaxation training,
electromyograph biofeedback, and hypnotic training have been included in
treatment programs focusing on the reduction of emotional disturbances in the
HIV population. Research pertaining to the use of cognitive-behavioral therapy
for helping patients cope with death has not yet been investigated. A review of
the literature has demonstrated that behavioral interventions, such as in vivo
and imaginal exposure focusing specifically on the fear reduction of existential
aspects associated with disease progression, have not been utilized for HIV
infected and other terminally ill populations (Thomason, Bachanas, & Campos,
1996). An integration of death anxiety and behavior therapy literature, lending
support for the use of exposure-based interventions for HIV infected persons
experiencing clinically significant levels of death anxiety, is presented.
Suggestions for the assessment and construction of in vivo, imaginal, and
virtual-reality exposure hierarchies will provide a framework for future
treatment and research.
Death Anxiety in
the HIV Population:
Implications for Exposure-based Interventions
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 (Dilley,
Pies, & Helquist, 1989; Kooner et al., 1989, Hintze, Templer, Cappelletty, &
Frederick, 1993). Elevated rates of panic, obsessive-compulsive (body-scanning
compulsions), and generalized anxiety disorders in the HIV-infected population
have been reported (Treisman, Fishman, Lyketsos, 1994). Rumination concerning
physical appearance (Miller, 1990), compulsive checking for new signs of disease
progression (Maj, 1990; Ostrow, 1990), and excessive vigilance and exaggerated
reactions to harmless bodily signs are widely observed (Kessler, 1988). Past
research has provided strong evidence for the existence of death anxiety in the
HIV population. (Franks, Templer, Cappelletty, & Kauffman, 1990; Hintze et al.,
1993; Hayslip, Luhr, & Beyerlein, 1991; Catania, Turner, Choi, & Coates, 1992).
At the present time,
only behavior change strategies such as assertiveness skills training,
increasing daily exercise, meditation, progressive muscle relaxation training,
electromyograph biofeedback, and hypnotic training have been included in
treatment programs focusing on the reduction of emotional disturbances in the
HIV population (Taylor, 1995; Antoni et al., 1990; Antoni et al., 1991;
LaPerriere et al., 1990; Mulder et al., 1995; Mulder et al., 1994; Kelly et al.,
1993). 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, Thomason, Bachanas, & Campos, 1996). A review of
the literature has demonstrated that behavioral interventions, such as in vivo
and imaginal exposure, focusing specifically on the fear reduction of
existential aspects associated with disease progression, have not been utilized
for HIV infected and other terminally ill populations. A recent literature
review (Thomason et al., 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.”
The following paper
will integrate previous death anxiety and behavioral literature, lending support
for the use of exposure-based interventions for HIV infected persons
experiencing clinically significant levels of death anxiety. Suggestions for
the assessment and construction of in vivo, imaginal, and virtual-reality
exposure hierarchies will provide a framework for future treatment and
research. Decreasing death anxiety can help HIV infected individuals cope with
their illness more effectively, manage environmental stress, and improve their
quality of life.
Literature Supporting the Use of Exposure-based
Interventions
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. If the fear of death is partly learned, then according to the
principles of learning, it can be unlearned or augmented. Adaptive information
could be integrated into a person’s view of death, subsequently decreasing ones
fear of death.
Death
education programs and experiential 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 (Murray, 1974;
Polderman, 1976; Bailis & Kennedy, 1977; Laube, 1977; McClam, 1980b; Whelan &
Warren, 1980). Death education involved didactic methods such as lectures,
discussions, and audiovisual teaching. Experiential methods have required
participants to imagine and discuss their thoughts and feelings about having
only twenty-four hours in which to live (Berman, 1972). Results of didactic
oriented death education interventions for the treatment of death anxiety failed
to reduce death anxiety, and in some studies, increased death anxiety. The
literature suggests that didactic approaches increase defenses against death
anxiety resulting in an increase in symptomatology in some cases. In contrast,
experiential approaches tended to decrease the fear of dying. The data in these
studies suggest that experiential exercises elicited intense personal
experiences that inhibited the avoidance of fear evoking information and allowed
for new information to augment previous fears (Lonetto & Templer, 1986).
Perhaps experiential approaches operate on similar principles as behaviorally
oriented fear reduction techniques such as prolonged exposure and
desensitization procedures.
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
(Bohart & Bergland, 1979; Testa, 1981). Results of these studies indicated that
desensitization procedures provided only moderate decreases in death anxiety.
The majority of these studies recruited subjects who did not exhibit high
baseline levels of death anxiety. Interestingly, none of the studies employing
desensitization and implosive techniques recruited subjects who were faced with
imminent death or were terminally ill. Lonetto & Templer (1986) suggest that
desensitization techniques could be more effective if high death anxiety
resulted from personal experiences pertaining to the matter of death. 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 routinely utilized in the behavioral treatment of
phobias, trauma and obsessive compulsive disorder (Foa & Kozak, 1985, 1986;
Craske & Barlow, 1994).
HIV patients who
experience an inordinate fear of death may be routinely avoiding fear-evoking
cues (images, thoughts, physiological fluctuations, and situations) associated
with death. The persistent avoidance of these cues may result in a strong
negative valence associated with death, subsequently leading to a failure to
integrate corrective, reality based information such as the acceptance and
inevitability of death. Death instead is viewed as a horrific event instead of
an eventual outcome. An acceptance of the possible shortening of ones life due
to an illness such as AIDS is avoided resulting in ruminative and obsessive
ideation. As with other anxiety disorders, HIV infected persons with an
inordinate fear of death may perceive an exaggerated probability that discomfort
anxiety lasts indefinitely.
Suggestions for Assessment and
Treatment
Assessment and Behavioral Analysis: A detailed behavioral analysis should be
conducted before implementing exposure based interventions. The behavioral
analysis focuses on the physiological, social, environmental, physical, and
cognitive stimuli that evoke fear reactions. Exposure hierarchies should be
carefully constructed to adequately evoke individualized fear structures. The
recording of avoidance and escape behavior, routinely exhibited by the patient,
will help assist in response prevention procedures. In addition to self-report,
psychological testing focusing on death anxiety can prove useful in providing
information for constructing hierarchies. Psychological measures that may
provide useful information include the Death Anxiety Scale (Templer, 1970),
Threat Index (Krieger, Epting, & Leitner, 1974), and the Multidimensional Fear
of Death Scale (Hoelter, 1979a). Clinicians should develop exposure hierarchies
based on consistent patterns of responding across the various tests
administered, corroborated by a clinical interview and behavioral observations.
Prospective patients should exhibit high levels of Death Anxiety on both
objective measures and subjective report. Patients should be instructed in the
theory and method of prolonged exposure to increase compliance with treatment.
In vivo exposure:
In vivo exposure interventions focusing on external objects or situations that
evoke high levels of death anxiety may prove useful for treatment. Suggestions
for in vivo desensitization include visiting HIV infected persons diagnosed with
AIDS, and visiting grave sites of deceased HIV infected lovers and friends.
Video and television programming on HIV/AIDS and photographs of the deceased may
prove as less anxiety provoking stimuli when creating various levels of exposure
intensity. Self-disclosure in the safe environment of a support group may
gradually desensitize HIV patients to anxiety stemming from the uncertainty of
the future regarding disease progression and feelings of shame. While attending
support groups, patients can acquire new coping skills modeled by others coping
more effectively. The acquisition of new coping skills can also reduce the
possibility of premature discontinuation from exposure interventions.
Imaginal and Virtual
Reality Exposure: Patients can imagine feared images of symptoms expected
from HIV related illnesses such as: tumors, sores, bodily disfigurement, and
weight loss. Virtual reality and computer imaging technology have been
successfully used to desensitize patients with phobias of flying and spiders
(Rothbaum, Hodges, Watson, Kessler, & Opdyke, 1996; Carlin, Hoffman, & Weghorst,
1997). Virtual Reality and computer imaging technology can facilitate the
activation of feared images of physical symptoms for patients who have
difficulty generating or maintaining images. Sores, weight loss, and other
physical symptoms can be superimposed onto pictures of patients who are
asymptomatic. Exposure hierarchies can be developed demonstrating a patient’s
possible appearance at different stages of HIV disease. Computer generated
images of disease progression viewed in a fluid progression could intensify the
effect of the exposure.
Patients can
develop detailed scripts that describe sensory information, thoughts, and
feelings associated with the fear of death and uncertain future concerning
disease progression. Patients could also write their obituaries and imagine
their own funerals to help accept the eventuality of death. An audiotaped,
videotaped, computer disk, or CD-ROM recording of a previous session, assigned
as homework for patients to review between sessions, can increase treatment
efficacy.
Incorporation of
Cognitive Restructuring: The recent incorporation of cognitive restructuring
techniques with exposure interventions for the treatment of post traumatic
stress disorder (Calhoun & Resick, 1993) could also be utilized to facilitate
the treatment of death anxiety in HIV infected patients. Once the fear
structure has been sufficiently activated using exposure-based interventions,
cognitive restructuring techniques and corrective information can be presented
to help patients restructure dysfunctional beliefs to facilitate the processing
of disturbing images and thoughts. Irrational beliefs concerning self worth
issues and the unpredictability of disease progression can be challenged once
the patient’s fear structure has been sufficiently activated. Effective
rational beliefs can be suggested to replace past irrational beliefs that have
been successfully disputed.
Conclusion
This paper has integrated
death anxiety and behavioral literature, providing support for the use of
exposure-based interventions with HIV infected individuals experiencing an
inordinate fear of death. The presented outline for assessment and treatment
now needs to be implemented and empirically validated. We encourage therapists
to utilize our suggestions to determine whether exposure-based interventions are
a viable option for the treatment of death anxiety for HIV patients. In
addition, the proposed outline for assessment and treatment may provide a
promising option for patients diagnosed with other terminal and life threatening
illnesses such as cancer and kidney disease.
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