According to the Diagnostic and Statistical Manual of Mental Disorders (DSM IV-TR), adjustment disorders are characterized by the development of emotional or behavioral symptoms in response to an identifiable stressor(s).² The symptoms or behaviors are considered clinically significant when they cause impairment in social or occupational function that is in excess of what would be expected from exposure to the stressor. Patients experience anxiety, depression, or a mixture of emotional and behavioral symptoms. Patients positive for HIV infection are at higher risk for developing adjustment disorders for several reasons. The initial fear of becoming HIV-positive is followed by emotional responses to the diagnosis, treatment, and ongoing disease-related stressors. Such stressors often overwhelm the patient’s capacity to cope emotionally with HIV and AIDS. In advanced stages of AIDS, many patients are increasingly physically and emotionally dependent on their caretakers. An increased need for dependency is particularly conducive to developing symptoms of adjustment disorder. Finally, people most vulnerable to HIV infection, such as intravenous drug users and persons with multiple sex partners, are also at risk of having a history of exposure to chronic stress throughout their lives. Individuals with a history of exposure to chronic stress may have more symptoms of distress when exposed to minor adverse events.³ Most patients with adjustment disorder return to normal functioning or to a new emotional equilibrium once the stress abates; patients with HIV, however, are faced with repetitive, multiple, concurrent stressors, making resolution of the adjustment disorder much less likely.

The stress connected with the onset of the HIV epidemic, once experienced by the entire nation, now affects mostly patients, their lovers, caretakers, and families. Caretakers of persons living with HIV disease and AIDS must deal with the stigma of HIV infection, uncertainty about the future, and increasing demands of caretaking as the disease progresses. Couples, especially HIV-discordant couples, face the risk of sexual transmission of the virus, the challenges of maintaining a safe and satisfying intimate relationship, and prospect of the loss of a lover. Not only do both HIV-positive and HIV-negative members of HIV-discordant male couples experience elevated levels of distress compared to the general population, but also there is concordance noted in the level of distress reported by each partner of the HIV-discordant couple.⁴

When a mother or father learns that she or he is HIV-positive, the entire family is confronted with multiple stressors. The unaffected parent may fear sexual transmission, and both parents may worry about disease transmission to their children. Parents must continue caring for children while coping with the unpredictable course of the illness, declining health, and complicated medication regimens. Additionally, parents must decide how to tell children about their HIV status. Children who are coping with the anticipatory loss of a parent may need to assume the responsibility of caring for younger siblings, doing housework, or providing emotional support to the ailing parent. Role functions within the family often are renegotiated, abandoned, or reorganized. Thus the emotional distress of the HIV-positive parent is experienced by the entire family.⁵ In a cohort of perinatally HIV-infected children, Mellins et al.⁶ reported that higher care-giver distress, worse parent–child communication, and lower caregiver quality of life predicted nonadherence of infected children to antiretroviral therapy. Managing such problems becomes critical because successful viral suppression requires 90% or better adherence to HAART medication regimens, and thus nonadherence becomes a life-threatening issue.

The following case illustrates the impact of stress in a family with an HIV-infected father:

Theresa, an Italian-American woman, mother of three young children, had been caring for her husband, who was dying of AIDS. He had acquired HIV infection through multiple extramarital affairs. Theresa felt ashamed of her husband’s illness and his affairs and worried that if her church, friends, or family found out, she would be ostracized because
of their fears of contracting HIV infection. The patient isolated herself and, as a result, had no support system while caring for three children and a dying husband. Her oldest child began to miss school as a result of worrying about his mother and father. Theresa was concerned about her son’s progress in school, but felt unable to approach his teacher for fear that either she or her son would be ostracized. As a result, she felt even more helpless and isolated. After her husband died, things grew worse. Although Theresa no longer had to provide care for her dying husband, she was left with grief and unresolved anger. She was unable to express or process any of these emotions, and the distraction of caring for her husband, which previously had provided her only method of coping, was gone. Her psychiatric treatment is described in the discussion of treatment considerations.

The response to stressors is affected by the individual’s appraisal and coping. Effective coping may have a restorative effect on the immune system and slow HIV progression.⁷ Gray and Cason⁸ defined effective coping as a process in which the individual accurately appraises the stressor and the available supports and mobilizes resources to master a particular stressor. In HIV-discordant male couples, Remien et al.⁴ reported higher levels of distress in each partner when self-blame and avoidance coping strategies were employed and HIV-related issues were not discussed.

In a study of women living with HIV/AIDS, mastery over stress was positively correlated with social support and a spiritual perspective. Interpersonal conflict correlated with decreased mastery over stress, possibly by reducing the available social support.⁸

Leserman et al.⁹ noted that use of active coping strategies and less use of denial were associated with a decreased likelihood of developing HIV-related symptoms. In men living with HIV who reported greater satisfaction with social support, Leserman et al.⁹ found a decreased disease progression. According to O’Cleirigh et al.,¹⁰ in patients with rheumatoid arthritis and asthma, the frequency of expressing either positive or negative emotions about one’s medical condition was linked to better clinical outcomes. In 2003, the same authors reported that compared to an HIV-seropositive comparison group, a cohort of long-term HIV survivors reported higher levels of emotional expression and depth processing of traumatic events (depth processing is a measure of the extent to which an individual worked through or attempted to resolve the stressor). Both emotional expression and depth processing were related to long-term survival; depth processing mediated the relationship between emotional expression and long-term survival. Depth processing of traumatic experiences by HIV-infected persons was related to perceived stress and antiretroviral medication adherence. In women, depth processing was positively related to CD4+ lymphocyte count, and emotional expression was both positively related to CD4+ lymphocyte count and negatively related to viral load.¹⁰ Recently bereaved men who reported finding meaning in bereavement had a slower decline in CD4+ cells and lower rates of mortality due to AIDS at a 2- to 3-year follow-up.¹⁰