Table of Contents

1. Introduction
2. Post-Traumatic Stress Disorder (PTSD)
   1. Presentation
   2. Diagnosis
   3. Management of Survivors of Trauma
3. Acute Stress Disorder (ASD)
4. References
5. Further Reading

I. Introduction

Exposure to a traumatic event is normally accompanied by distress.

For most individuals, such distress resolves spontaneously without the onset of any psychiatric illness. Among a subset of people, the type, severity, and duration of symptoms following trauma will meet the criteria for either acute stress disorder (ASD) or post-traumatic stress disorder (PTSD).

ASD is not as well studied as PTSD.

Some trauma researchers feel ASD is on a continuum with PTSD and that the cut-off times for the two disorders are arbitrary.

Therefore, a more detailed description of trauma and its treatment is provided in Section II: Post-Traumatic Stress Disorder.

Trauma can affect both psychological and physical functioning.

Some research has suggested that the physical effects of trauma have been related to significant health problems, such as diminished functioning of the immune system and increased susceptibility to infections.

The psychological effects of PTSD may manifest in increased risk-taking behavior, such as substance use, poor eating habits, or unsafe sexual activity.

In addition, patients with PTSD may suffer from depression, social isolation, impairments in trust and attachments, and feelings of anger.

Patients with HIV/AIDS may be affected by past trauma to the point that it manifests in problems with disease management, such as disrupted or negative interactions with medical personnel and/or medication non-adherence.

II. Post-Traumatic Stress Disorder (PTSD)

PTSD can result from a single traumatic event, such as a car accident, rape, or experience of a natural disaster, or an ongoing pattern of traumatic experiences, such as childhood abuse (physical and/or sexual), domestic violence, homelessness, military duty or combat, or severe chronic illness. Because the psychological symptoms that commonly occur following a traumatic event may remit spontaneously over time for most people, some researchers conceptualize PTSD as a disorder of recovery.

A history of previous traumatic experiences increases a person's vulnerability to developing PTSD upon exposure to subsequent trauma. Previous traumatic experiences may impair his/her ability to handle future stressors. The more severe the trauma, the greater the likelihood that the patient will develop PTSD.

The rate of PTSD following exposure to a particular trauma ranges from 12% to 70%, with the higher rates occurring in populations exposed to interpersonal violence (e.g., rape, sexual abuse, torture). Women have higher rates of PTSD than men. Among women, sexual assault is the most common precipitating trauma, whereas, among men, the most common trauma is combat exposure.

Although PTSD has a lifetime prevalence rate of approximately 1.3% to 7.8% in the general population, the rates of PTSD in the HIV-infected population are higher.

The prevalence of PTSD in HIV-infected individuals may be as high as 42%.¹ Although the onset of a severe, life-threatening illness (such as HIV/AIDS) can sometimes be a traumatic experience leading to PTSD, more often, a history of physical or psychological trauma (and diagnosis of PTSD) co-occurs with an individual's HIV status.

Among people with the most severe mental illnesses, specifically schizophrenia, schizoaffective disorder, and bipolar disorder, comorbid PTSD is a significant predictor of HIV infection.²

A. Presentation

Patients with PTSD may show a variety of symptoms, which must persist for more than 1 month to meet the criteria for PTSD. The symptoms may be straightforward or may vacillate between overwhelming emotions caused by memories of the event and emotional numbness and dissociation. Dissociation is a disruption in the ordinary integration of consciousness, memory, or identity. It can present as flashbacks, depersonalization, derealization, and/or episodes of lost time.

B. Diagnosis

Recommendations:

The primary care clinician should screen for PTSD annually or more often as clinically indicated.

Clinicians should use the criteria listed in the DSM-IV for a diagnosis of PTSD in patients with HIV/AIDS (see Table 1).

Clinicians should screen patients with PTSD or significant trauma histories for clinical depression, anxiety disorders, or alcohol or other substance use disorders.

In patients with a history of traumatic experience, it is important to assess for the presence of PTSD by asking about the experience of the trauma and reviewing the symptoms. PTSD is diagnosed when symptoms have been present for more than 1 month and an individual meets the other criteria listed in Table 1.

C. Management of Survivors of Trauma

Recommendations:

Clinicians should refer patients with symptoms of PTSD to a mental health professional as soon as possible for evaluation for psychotherapy or other forms of psychiatric treatment. The goal of treatment should be to reduce symptoms and fully reintegrate a safe sense of self.

If specialized services are unavailable, the primary care clinician should prescribe medications (see Appendix II) and monitor the improvement achieved with this strategy alone.

During the acute phase of treatment, clinicians should assess the patient's risk for harm to him/herself or others.

Some patients respond to medication and brief supportive interventions; most require psychotherapy and specialized mental health intervention.

However, if such services are unavailable, the primary care clinician should prescribe medication and monitor the improvement achieved with this strategy alone.

There is no single medication that treats all of the symptoms of PTSD.

Currently, sertraline and paroxetine are the only FDA-approved medications for PTSD.

Paroxetine should be avoided in patients less than 18 years old because of its possible association with increased suicide risk.

All SSRIs (in the same doses used for depression) help treat symptoms of depression and anxiety. Moreover, controlled and open studies of various SSRIs and other antidepressants have shown benefits in treating PTSD symptoms.³

Open trial studies of mood stabilizers have also shown some benefits. Long-term benzodiazepine use is not a preferred treatment.

If benzodiazepines are prescribed, careful monitoring is required due to the potential for abuse and concerns about disinhibition in those with significant dissociative symptoms.

Empirically validated psychotherapy treatments include exposure therapy, anxiety management programs, and cognitive therapy.

These treatments modify fear and false cognitions created in response to single or multiple traumas and improve coping skills in the face of new stressors.

Treatment is offered through individual and group modalities.

Several studies show that psychodynamic treatments can also be helpful.

Early evidence supports the concurrent treatment of PTSD and addiction.

III. Acute Stress Disorder (ASD)

Recommendation:

For patients who meet the criteria for ASD, clinicians should follow the same guidelines as those recommended for managing PTSD (see Section II. C: Management of Survivors of Trauma).

Many of the symptoms of ASD (see Table 2) overlap with those of PTSD. ASD defines as a severe stress response that follows shortly after a traumatic event, whereas PTSD cannot be diagnosed until symptoms have persisted for 30 days or longer.

The presence of full or partial ASD is associated with an increased risk of developing PTSD.

In various studies, numbing, depersonalization, a sense of reliving the trauma, motor restlessness, and peri-traumatic dissociation was found to predict progression to PTSD.⁴

These associations raise the possibility that effective early treatment of trauma symptoms can be a useful strategy in preventing PTSD.

However, it should be noted that many trauma survivors who develop PTSD do not have initial ASD symptoms, and many individuals with ASD will not develop PTSD.

References

1. Cohen M, Hoffman RG, Cromwell C, et al. The prevalence os distress in persons with human immunodeficiency virus infection. Psychosomatics 2002;43:10-15.

2. Essock SM, Dowden S, Constatine NT, et al. Risk factors for HIV, hepatitis B, hepatitis C among persons with severe mental illness. Psychiatr Serv 2003;54:836-841.

3. Cooper J, Carty J, Creamer M. Pharmacotherapy for posttraumatic stress disorder: Empirical review and clinical recommendations. Aust N Z J Psychiatry 2005;39:674-682.

4. Harvey AG, Bryant RA. The relationship between acute stress disorder and post-traumatic stress disorder: A prospective evaluation of motor vehicle accident survivors. J Consult Clin Psychol 1998;66:507-512.

Further Reading

American Academy of Psychosomatic Medicine. Bethesda, MD. Available at: www.apm.org.

Bisson JI. Post Traumatic stress disorder. BMJ 2007;334:789-793.

Cohen MA, Gorman JM, eds. Comprehensive Textbook of AIDS Psychiatry. New York: Oxford University Press; 2008.

Fernandez F, Ruiz P, eds. Psychiatric Aspects of HIV/AIDS. 1st ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2006.

Foa EB, Stein DJ, McFarlane AC. Symptomatology and psychopathology of mental health problems after disaster. J Clin Psychiatry 2006;67:15-25.

Organization of AIDS Psychiatry. Bethesda, MD: Academy of Psychosomatic Medicine. Available at: www.apm.org/sigs/oap.

Yehuda R.  Biology of posttraumatic stress disorder. J Clin Psychiatry 2001;62:41-46.

Yehuda R. (ed.) Treating Trauma Survivors With PTSD. American Psychiatric Publishing Inc, Washington DC, 2002.

Nate woke up covered in sweat from the nightmare he had dreamt a thousand times. In it, he endlessly ran from the faceless man with the gun, breathless and fearful, waiting for the bullet that never came. Deprived of sleep, his days and nights often merged, clouded by a meth addiction that helped him escape the belief that he was damaged goods, or the pain of his survivor guilt, or the disorientation of living a life he never expected to have. As those dark, early days of the epidemic became a historical footnote, Nate felt even more alone and turned increasingly inward, using drugs and impulsive, anonymous hookups to numb emotional pain.

Nate was a survivor -- barely. In 1986, while still in his 20s, he was diagnosed with HIV. That day his life changed forever with a "death sentence" that quickly came true for dozens of his friends. Even as he cared for his dying lover, Nate was hospitalized numerous times, at his worst declining into a skeleton, covered with Kaposi's Sarcoma lesions and suffering early-stage dementia. Nate had no choice but to go on disability, losing a promising career and forfeiting his dreams, financial security, and belief in a future. For years Nate's sole focus was survival.

Then, in 1996, he received a new class of HIV medication and his symptoms began to abate. Like a brightening sky after a storm, Nate awoke from a decadelong nightmare, except the psychological effects of the trauma lived on in his head. His body stabilized in the years that followed yet he alternated between overwhelming grief and anger. He withdrew, keeping his grief private, not even allowing himself to feel it lest he be overwhelmed. With each year that passed, fewer people even remembered the terrible early days of the epidemic, leaving Nate feeling alienated, damaged and alone.

Thousands of other survivors who lived through the devastation of the 1980s and 1990s continue to share similar feelings. While trauma can lead to symptoms such as depression, flashbacks, nightmares, and conditions such as Post Traumatic Stress Disorder (PTSD), long-term survivors of HIV (LTS) experienced a sustained, relentless trauma over the course of several decades, resulting in a spectrum of symptoms that appear to have created a syndrome unique to this population and more similar to what is called complex PTSD. This cluster of symptoms, named AIDS Survivor Syndrome (ASS) by activist and long-term survivor Tez Anderson, have not, until now, been scientifically assessed. That has changed and it appears ASS is indeed a real syndrome.

Related: Living and Aging Well With HIV: New Strategies and New Research

Recounting those early days, Tez Anderson states, "many of us went down a rabbit hole, experiencing years of anger, anxiety and poor sleep with nightmares." People were universally told to make plans to die, all the while stigmatized and, in many cases, abandoned. To address these issues Anderson started a grassroots organization in San Francisco called Let's Kick Ass: AIDS Survivor Syndrome which pays tribute to the experience of survivors and creates opportunities to heal emotional pain with community and tools such as gratitude and sense of purpose.

Anderson intuitively understood how it felt to live with ASS, but there was no scientific research to validate it. At the same time, Dr. Ron Stall, a noted HIV researcher, Professor of Public Health at the University of Pittsburgh and investigator of the Multicenter AIDS Cohort Study (MACS), became interested in the concept, noting that "street epidemiology tends to be pretty correct and street wisdom raises questions that are worth looking into very carefully." Dr. Stall's research has long focused on resilience in the face of adversity, especially regarding both HIV and addiction among gay men. By further defining ASS he hopes to identify strengths and characteristics of resilience among those who survived.

Dr. Stall and a research team examined records selected from the MACS study, a longitudinal research project of over 7,000 men with and without HIV dating back to the 1980s. They identified nine variables such as feeling depressed or isolated, or not believing one had a future, and then examined prevalence of these symptoms among men living with HIV and enrolled in the MACS study. Stall found that 22% reported experiencing three or more of the identified symptoms either "fairly frequently," "at least once a week," or "every day." This high prevalence appears to validate the concept of ASS and, with factor analysis, will provide a conceptual basis for the development of resilience-based interventions.

Stall and his team are in the early stages of exploring AIDS Survivor Syndrome but several things have become clear. The men in the epidemic, with or without HIV, experienced personal losses that numerically exceeded those sustained in World War I and which resulted in substantial psychological distress. The factors (symptoms) examined in the data appear to be strongly related to each other and variance among them seems to be best explained by a single factor. Definitively distinguishing AIDS Survivor Syndrome from depression or PTSD remains to be completed but long-term survivors have already found that the emerging shape of AIDS Survivor Syndrome validates their lived experience.

Much work remains to be completed. For example, do ASS variables function similarly across different groups such those living or not living with HIV, racial minorities, or age cohorts? Do HIV-positive men who score higher on ASS measures have worse viral load trajectories over time, or do certain resiliencies moderate the effects of ASS on viral load outcomes among HIV positive men? Armed with these data it will be possible to create interventions to address the needs of survivors. This may entail adaptation of existing therapies for depression and/or PTSD, or the development of interventions built from the ground up. They will be increasingly important as the cohort of survivors from the 1980s and 1990s ages along with uncertainties due to the physical and psychological consequences of a lifetime with HIV.

The enormity of the AIDS epidemic on the lives of survivors cannot be overstated. Overwhelming loss, stigma and discrimination, lifelong physical injury such as neuropathy, and psychological consequences, all under the specter of imminent death, have done real harm. As the scientific evidence for AIDS Survivor Syndrome takes shape, the experience of survivors is validated and opportunities to thrive and create resilience can be developed. Anderson, puts it this way: "For survivors who have wondered what their experience with HIV means now that it is considered a chronic illness, or who have struggled to express their condition to health care providers, this study harvests hope, allowing LTS to reauthor their story and find meaning and purpose."

Get updates on research and information at Let's Kick Ass. Learn more about HIV Long-Term Survivors Awareness Day, which is June 5, 2018.