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Cognitive Behavioral Stress Management of HIV InfectionsOriginsEarly approaches to cognitive stress intervention focused on helping police officers cope with stress (), and a cognitive behavioral stress management training for treating migraine (). A report published in 1986 compared a program of cognitive behavioral stress management (CBSM) to aerobic training and weight training, for the treatment of Type A personalities (). Significantly greater reduction in behavioral reactivity was seen with CBSM but not physiological reactivity. In 1989, a study was published on stress management based upon transactional stress and group treatment theory (). The treatment was conducted over 8 weeks at 2 hours per week, and consisted of instruction in cognitive-behavioral skills of relaxation, cognitive restructuring, and assertiveness in a small group setting. Compared to wait list controls, those who received treatment showed significant reductions in stress. Cognitive behavioral stress management techniques stepped up to a higher level with the publication of a seminal paper in 1991 that showed psychological cushioning of both stress and immune reactivity in gay men who had just learned that they were HIV-positive (). In this RCT, five weeks before notification of their HIV status, 47 asymptomatic gay men were assigned to an assessment only control group or to a CBSM program. Three days before and one week after notification, blood samples and psychological measurements were taken. Compared to baseline, seropositive controls showed significantly increased depression and slight decreases in proliferative reaction to mitogens and lymphocyte counts. The CBSM group showed no significant increases in depression; and they demonstrated significant increases in CD4 and NK cell counts, and a slight increase in proliferative reaction to mitogens. The RCT’s authors hypothesized that these benefits may have been due to increased relaxation or willingness to participate in the intervention guidelines. ProgramDeveloped by Michael Antoni, Gail Ironson, and their colleagues at the University of Miami (, , , ), multimodal cognitive behavioral stress management (CBSM) helps alter cognitive appraisals, teaches new coping strategies and relaxation, and encourages access to social support, and it may improve the quality of life in HIV infected men () and women (, ). CBSM is based upon social support theory that stress is easier to handle in a positive social context. The 10-week CBSM program is a mixture of emotion-focused and problem-focused coping strategies. Sessions are typically 90 minutes of didactic expressive supportive therapy followed by 30 minutes of relaxation. Groups usually consist of 4 to 8 individuals. The CBSM intervention is often referred to as GET SMART (Group-Experienced Therapy for Stress Management and Relaxation Training). CBSM with an added expressive supportive component is called SMART/EST or CBSM+. Various stress management techniques are presented and the group participants are encouraged to discuss these techniques and associate them with the stressors they may be experiencing. One or more group activity, such as role playing, group interactions or in-session worksheets, is introduced in each session and the participants are encouraged to practice these relevant techniques. CBSM includes:
Journal ArticlesLet us look at some of the seminal papers using CBSM. In an RCT, 40 HIV+ gay men were randomized to receive 10 weeks of CBSM (n=22) or were put on a wait-list as controls (n=18) (). Coping, mood, and social support were assessed before and after the experiment. Compared to controls, the CBSM group evidenced significant improvement in coping skills that used positive reframing and acceptance, and in social supports involving attachment, alliances, and guidance. The control group actually showed decreased coping skills and no changes in social support. Better cognitive functioning, in particular acceptance of their HIV infection, highly correlated with less anxiety, dysphoria, and total mood disturbances. Changes in cognitive coping and social support appear to mediate the effects of CBSM on decreased distress. There is some suggestion that CBSM may lessen distress and depressed mood and normalize HPA functions in HIV+ gay men (). Symptomatic HIV+ gay men were randomly assigned to receive 10 weeks of CBSM or to 10 weeks as a wait list control. The 41 men who received CBSM showed significantly lower levels of post-treatment self-reported anxiety, anger, depressed affect, and confusion than the 19 men in the wait list control did. Of these groups, 47 men (34 CBSM, 13 controls) gave urine samples. The CBSM men showed significantly less 24-hour urinary cortisol than the wait list controls. For each individual, some aspects of distress, especially depressed mood, paralleled decreases in cortisol. CBSM effects on anxiety, 24-hour urinary norepinephrine output, and cytotoxic/suppressor T cells (CD3+CD8+) were examined in an RCT of 73 HIV+ gay men (). A 10-week CBSM intervention was provided to 47 of the men while the 26 others were wait-list controls. The CBSM group vs. the control group demonstrated significantly lower post-treatment self-reported anxiety, anger, total mood disturbance, and perceived stress. They also had less norepinephrine output. Individual levels of decreased anxiety paralleled the norepinephrine reduction. Six to twelve months after the experiment, the CBSM group vs. the control group showed significantly more cytotoxic/suppressor T cells. More practice of relaxation in the CBSM group and greater decreases in urinary norepinephrine predicted greater number of cytotoxic/suppressor T cells. Perhaps cognitive behavioral interventions may modulate the HPA axis through the vehicle of decreasing depressed mood. CBSM in HIV positive men may modify the stress of symptomatic disease and the rate of immune system reconstitution (). In an RCT, 25 symptomatic HIV-positive men were assigned either to a 10-week CBSM or to a wait list control. Twenty-four hour cortisol urine samples and pre- and post intervention (6 and 12 months) questionnaires were conducted and compared with CD4/CD45RA/CD29 lymphocytes levels (a measure of immune system reconstitution). Independent of medications or health behaviors, there was a greater reduction in cortisol levels and depressed mood during CBSM and seemed to be associated with the indicator of immune system reconstitution at 6- and 12-month follow up. Reliance on denial coping, which may be stress reducing in the short term but harmful over time, may be reduced by a CBSM intervention (). CBSM combined with medication-adherence training (MAT) was assessed in 76 gay and bisexual HIV-infected males and 54 matched controls who received MAT only. During the 10 week intervention, depressed mood, avoidant coping (denial and disengagement), active cognitive coping (acceptance and positive reinterpretation), and self-reported adherence were assessed. CBSM combined with MAT produced no changes in active cognitive coping or self-reported adherence, but there was less reliance on avoidant coping and depressed mood. Those folks who reported more denial in the beginning seemed to be less depressed after the CBSM plus MAT. Follow up on the above study () assessed HIV-viral load at 9 months and 15 months after the 10-week CBSM program began (). Although no differences were seen in viral load among the participants, those men who began the study with detectable HIV (n =101) demonstrated a significant decrease in viral load if they received the CBSM plus MAT (n =61). When adjusted for medication adherence, these men showed 0.56 log10 decrease in viral load. Those who got MAT only, showed no change. It appears that decreased depressed mood during the intervention may have been responsible for the suppression. An RCT of CBSM HIV-seropositive men, compared to wait-list controls, demonstrated significant increases in testosterone, significant decreases in distress, and an inverse relationship of testosterone to distress independent of cortisol (). Herpes simplex virus type 2 (HSV-2) appears to be more prevalent in folks with AIDS and may be a risk factor for HIV transmission and disease progression (, , ). Herpes viruses that are kept in check by our immune system can tip the host vs. pathogen balance into their favor when we are physically and psychologically stressed (, , , , , , ). These changing balances are often associated with increased levels of specific circulating antibodies. An RCT investigated CBSM effects on HSV-1 and HSV-2 antibody titers, CD4, and CD8 cells, and dysphoric mood in symptomatic HIV+ gay men (). The 10-week-CBSM intervention group experienced a significant decrease in self-reported dysphoric mood, anxiety, and total distress, and decreased anti HSV-2 titers but not anti HSV-1 titers. Less dysphoria significantly predicted lower HSV-2 antibody titers. The control group displayed no significant changes in mood or antibody titers. CBSM has been shown to significantly decrease self-reported dysphoria, anxiety, and total distress in HIV-seropositive gay men whose disease had become symptomatic ({%X_91037320%}). Those men who most consistently practiced relaxation reported the biggest improvement in dysphoria. Although there were no changes in CD4 or CD8 cells numbers or changes in antibodies to HSV-1, greater improvements in dysphoria were associated with lower titers of antibodies to HSV-2. In mildly symptomatic HIV positive gay men, increased perceived receipt of guidance, a type of social support, resulting from CBSM was associated with significant reduction in anti-HSV-2 IgG titers (). Lower mean stress levels tied to home relaxation practice was associated with the decreased anti-HSV-2 titers. Decreased cortisol to DHEA-S ratios (q.i.) was associated with decreased anti-HSV-2 IgG titers. Effects of aerobic exercise, assessment only control, and CBSM were assessed on Epstein-Barr virus viral capsid antigen (EBV-VCA) and human herpes virus type 6 (HHV-6) antibody titers in 65 asymptomatic gay men (). These men were monitored for 5 weeks before and 5 weeks after receiving diagnosis of HIV status. Compared to those who were diagnosed as HIV negative, all those who were diagnosed as HIV positive had higher EBV-VCA titers but not HHV-6. Compared to controls, those who received either aerobic or CBSM interventions had decreased EBV-VCA and HHV-6 titers during the intervention. Although the interventions decreased anxiety and depression, in this study no correlations were seen with changes in CD4, CD8, CD4 to CD8 ratios, or antiviral antibody titers. CBSM has also been investigated as an intervention to improve behavioral and psychosocial changes and hence endocrine and immune functions in mildly symptomatic HIV-infected gay men (). In an RCT, 62 HIV positive gay men were randomly assigned to a CBSM intervention (n=41) or a wait list control (n=21). At baseline and 10 weeks later, stress level before and after at home relaxation (for the CBSM recipients), social support, anxious mood, ratio of cortisol to dehydroepiandrosterone sulfate (DHEA-S), and anti-herpes simplex virus type 2 (HSV-2) IgG were evaluated. HSV-2 is a common co-infectant in HIV-infected people. After 10 weeks, CBSM participants vs. controls had significantly reduced anti-HSV-2 titers. Perceived social support partially mediated the effect. Lower mean stress after at home relaxation was associated with greater decreases in these titers. And decreases in cortisol to DHEA-S ratios were associated with decreased HSV-2 titers. A SMART/EST group intervention plus a healthier lifestyles component was compared with an individual educational/informational format plus a healthier living component on HIV-medication adherence in 237 women who were predominately Latina or African-American (). Group participants vs. individual participants reported greater emotion-focused coping and greater medication adherence. These same women were followed for one year to determine the duration of effects (). The group showed maintenance of significantly decreased depression scores on the Beck’s Depression Inventory at one year follow-up. Certain attributes of quality of life (QOL) in women with AIDS have been shown to be increased by SMART/EST or individual psychoeducational interventions (). Overall QOL scores, and the QOL domains of cognitive functioning, health distress, and overall health perceptions increased for both interventions. However, women in the SMART/EST group vs. the women who had individual psycho education showed significant improvement in mental health QOL. CBSM was compared to social support groups (SSG) and wait list controls (WAIT) for psychosocial functioning, quality of life, neuroendocrine mediation, and somatic health in 119 men and 29 women who had HIV disease (). CBSM participants showed significantly higher post intervention emotional well-being and total QOL scores compared to SSG and WAIT groups. Interestingly, the SSG group demonstrated significantly lower social/family well being scores immediately after the SSG intervention and lower social support after 6 months. Interest in CBSM is high enough that at least one study has set guidelines for cultural sensitivity in order to boost the benefits of CBSM (). SummaryThrough the use of cognitive coping strategies, relaxation, and social support, multimodal CBSM has shown great promise in improving psychological, neuroendocrinological and immunological functions in folks with HIV infection (, , , , ). These effects seem to operate on the sympathetic nervous system, and on the hypothalamic-pituitary-adrenal and hypothalamic-pituitary-gonadal neuroendocrine systems. Reduction in depressed mood has been associated with decreased cortisol, and increased serum DHEA-S and testosterone. Reduction in anxiety has been associated with decreased norepinephrine. Immunological effects have been shown on increased CD8 cytotoxic/suppressor cells, conversion of naïve CD4 cells, and boosting of antiviral antibody titers. |
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