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Subject(s): AIDS (Disease) -- Patients -- Psychology; IMMUNE system -- Psychological aspects Source: Health & Social Work, Nov96, Vol. 21 Issue 4, p287, 5p Abstract: Discusses the premise that the psychological state affects the immune system with reference to the psychological state of persons with enhanced functioning immune states and those with suppressed immunity, HIV and AIDS. How stress affects the immune system; How psychological health assists the immune system; Advantages of intervention on the psyche and immune system of HIV and AIDS patients. HOW PSYCHOLOGICAL STATES AFFECT THE IMMUNE SYSTEM Implications for Interventions in the Context of HIV Research has established that psychological states can affect the immune system. This article discusses the psychological states associated with enhanced immune system functioning and those associated with suppressed immune functioning. Studies of psychological and behavioral interventions to boost the immune systems of people who are HIV positive, including people with AIDS, are reviewed. Suggestions are made for group interventions to enhance psychological states associated with better immune system function. group work HIV/AIDS immune system psychological states Although medical social workers have always played a role in helping loved ones adjust to significant illness in a family member and in securing needed resources to pay for medical care (Furstenberg & Olson, 1984), a new role for mental health professionals in the care of those afflicted with disease has emerged. Data from the expanding area of psychoneuroimmunology show that how people feel and how people appraise their living situations can affect their immune systems via the white blood cells, which eliminate or incapacitate viruses, cancers, bacteria, and other microbes (Nee, 1995). Because mental health professionals have developed interventions for changing people's perspectives on life and their resultant feelings, it becomes possible, through psychological interventions, to influence immune system functioning. The literatures reviewed in this article assume an underlying model of illness that includes environmental events, coping mechanisms, psychological states, activation of particular regions in the nervous system, and immune system function as variables (Anton), Schneiderman, et al., 1990). The model explains how environmental events such as loss or trauma make immune system suppression more likely. However, immune suppression is the end result of a cascade of events involving mediating variables. The occurrence of an environmental stressor makes immune suppression more likely but by no means inevitable. Given an environmental stressor, people appraise the situation and have the option of acting in ways to reduce the impact of the stressor. The processes of appraisal and behaving to reduce the impact of the stressor are collectively called "coping." Depending on a person's coping mechanisms, particular psychological states can occur. A psychological state has a wide variety of manifestations. Psychological states are associated with activation of particular brain regions and regions in the autonomic nervous system; with particular overt affective behaviors (for example, crying, exhibiting a low threshold for anger, shaking with anxiety); and with particular self-reports of affect. Specific psychological states also have immune system consequences (Nee, 1995). Mapping out the chemical or neuronal messages between the nervous system (the source of psychological states) and the immune system is a vigorous area of current research (Maier, Watkins, & Fleshner, 1994). This article first examines some of the general findings relating personality variables, environmental conditions, and coping mechanisms to immune system function. The review of the literature focuses on the coping and psychological state step in the model of illness, the step at which the cascade of events can be influenced by the social worker. The purpose is to identify the psychological states or coping behaviors that are associated with immune system suppression and those that are associated with immune system enhancement. The implication is that social workers should encourage those outlooks or psychological states associated with immune enhancement and should discourage those associated with immune suppression. In addition to the general findings on how psychological factors relate to health, some specific studies conducted in samples of people with the AIDS virus are discussed. These studies too have shown that influencing psychological factors can affect the immune system in people with HIV who are asymptomatic and people with AIDS (PWAs). Extrapolating from these studies, interventions that will be useful for these people can be generated. STRESS AND THE IMMUNE SYSTEM: IMPAIRMENT OF FUNCTIONING Many of the initial studies exploring the impact of uncontrollable stress on the immune system examined the effects of stress in rodents. The investigators subjected rodents to unpredictable, uncontrollable shocks and studied subsequent responses. Following exposure to this procedure, rats behaved in a learned helpless fashion: They failed to act to escape subsequent, controllable shock (Seligman, 1991). Further, learned helpless animals were immunosuppressed. Their white blood cells (both T and B cells) exhibited attenuated division and proliferation when provoked by an appropriate stimulus. Their natural killer cells, the first line of defense against viral-infected and tumor cells, were less active (Laudenslager, Ryan, Drugan, Hyson, & Maier, 1983; Millar, Thomas, Pacheco, & Rollwagen, 1993; Shavit et al., 1985). Intrigued by the immune system suppression findings, investigators sought to identify the physical mechanisms that could account for immune suppression when an animal is exposed to uncontrollable shock. Although it had long been known that stress elevates levels of the adrenal gland hormone cortisol, which is itself immunosuppressive, early studies ruled out cortisol as the only major player in uncontrollable stress-induced immunosuppression (Keller, Weiss, Schleifer, Miller, & Stein, 1983). Later studies succeeded in locating brain regions involved in the uncontrollable stress-induced immune suppression. Subjecting an animal to uncontrollable, unpredictable shock activates an area of the brain called the periaqueductal gray area, which mediates immune suppression (Demetrikopoulos, Siegel, Schleifer, Obedi, & Keller, 1994; Weber & Pert, 1989). Activation of the periaqueductal gray is associated with behavioral manifestations, namely, the behavioral manifestations of learned helplessness (Mater et al., 1993). Squealing, defensive aggression, and defensive freezing are further observed when the periaqueductal gray of a rodent is activated (Mater et al., 1993). An anthropomorphic interpretation of the rodent's experience is that the rodent feels vulnerable. Many types of distressing events that human beings encounter appear to share essential features with the laboratory procedure of uncontrollable shock. A wide variety of stressful events are known to induce immune suppression in people. Medical students undergoing examinations exhibit immune suppression (Kiecolt-Glaser et al., 1984; Kiecolt-Glaser et al., 1986), as do caregivers of Alzheimer's patients (Kiecolt-Glaser et al., 1987), people who have lost a loved one (Bartrop, Luckhurst, Lazarus, Kiloh, & Penny, 1977), and women who are unemployed (Arnetz et al., 1987). People who experience greater daily stress show immune system depression (Stone et al., 1994). Depressed individuals, particularly those who are older or more severely depressed, are likely to be immunosuppressed (Schleifer et al., 1984; Schleifer, Keller, Bond, Cohen, & Stein, 1989). Further, depressed mood is associated with immune system suppression among people with AIDS who are not undergoing bereavement (Kemeny et al., 1994). The studies examining immune system suppression in people undergoing various types of environmental stress only sometimes identified the subjective psychological states that are probably the mediating state connecting environmental events to immune system function. In the studies on human beings, brain regions activated in psychological states that then influence the immune system have not been assessed. However, given the findings from the animal literature, it is reasonable to speculate that activation of the periaqueductal gray mediates the impact of environmental stress on immune suppression. PSYCHOLOGICAL HEALTH AND IMMUNE SYSTEM ENHANCEMENT A natural opioid substance, beta-endorphin, has been identified in the literature on immune system enhancement (Anton), Schneiderman, et al., 1990). Although there are findings to the contrary (Sacerdote, Manfredi, Bianchi, & Panerai, 1994), and although the relationship may be curvilinear rather than linear (Fiatarone et al., 1988), at particular levels betaendorphin has been associated with increased natural killer cell activity (Levy et al., 1991; Mandler, Biddison, Mandler, & Serrate, 1986). A number of behavioral and psychological interventions are known to alter endogenous opioid levels. Systematic desensitization, the treatment for helping individuals overcome phobias, increases beta-endorphin levels (Thyer & Matthews, 1986). Opioid antagonist drugs block the efficacy of systematic desensitization, suggesting that successful desensitization is mediated through endogenous endorphins (Arntz, Merckelbach, & de Jong, 1993; Egan, Carr, Hunt, & Adamson, 1988; Merluzzi, Taylor, Boltwood, & Gotestam, 1991). The self-efficacy of people who overcome phobias appears to be linked to endogenous endorphins as well (Bandura, O'Leary, Taylor, Gautheir, & Gossard, 1987). Aerobic conditioning such as that achieved by long-distance runners is associated with high betaendorphin levels. High beta-endorphin levels (or some concomitant) in long-distance runners may have psychological consequences. Those who are aerobically conditioned are less likely to respond to a mental stressor with elevated blood pressure and strong autonomic nervous system activation. Perhaps endogenous opioids play a role for people who engage in aerobic exercise in creating resistance to the effects of stress (Fiatarone et al., 1988; McCubbin, Cheung, Montgomery, Bulbulian, & Wilson, 1992). Consistent with the hypothesis that high beta-endorphin levels enhance the body's stress resilience, Post, Pickar, Ballenger, Naber, and Rubinow (1984) found lower plasma beta-endorphin levels in trait anxious persons. Studies linking psychological states with enhanced immune system functioning have appeared. In these studies the chemical mediators (for example, betaendorphin) of better immune system functioning were not identified. However, the picture is consistent with the view that a sense of efficacy (a correlate of high beta-endorphin levels) enhances the immune system. Heisel, Locke, Kraus, and Williams (1986) found that college students with lower elevations on the Minnesota Multiphasic Personality Inventory (Hathaway & McKinley, 1967) distress scales displayed stronger natural killer cell activity. Levy, Herberman, Maluish, Schlien, and Lippman (1985) found that cancer patients exhibiting a fighting spirit and greater optimism displayed stronger natural killer cell activity. Examination of the effects of behavioral and psychological interventions on endogenous opioids is in its infancy. The studies on runners have examined beta-endorphin specifically. The studies on systematic desensitization have established that the success of the procedure is attributable to some endogenous opioid substance, although the specific molecule has not been identified. The influence of plasma betaendorphin on immune function is only beginning to be explored. Future research should provide more specific findings on behavioral and psychological interventions for enhancing immune system functioning. Identification of endogenous physical mediators of immune enhancement can be expected to guide future research. PSYCHOLOGICAL COPING ASSOCIATED WITH LESS DISTRESS Referring back to the model connecting environmental events with psychological states, which in turn influence the immune system, coping is the step in the model that determines whether environmental events will result in the development of a psychological state of negative mood or a state of efficacy or strength. Data collected from HIV-positive people identify coping styles that result in particular psychological states that, in turn, exert immune system consequences. Support for the benefits of active cognitive and behavioral coping in people with HIV has been reported (Goodkin et al., 1992). Seeking out information about the disease, seeking out social support, focusing on meaning in life, and arranging the environment to avoid becoming distressed are coping skills associated with lower levels of distress (Fleishman & Fogel, 1994; Goodkin et al., 1992; Namir, Wolcott, Fawzy, & Alumbaugh, 1987). In a longitudinal study, active coping at time 1 predicted less distress 11 months later (Fleishman & Fogel, 1994). Beyond relating to psychological states, active coping styles are also associated with stronger natural killer cell activity (Goodkin et al., 1992), as are greater self-nurturing, less preoccupation with the disease of AIDS, and regular exercise (Temoshok, cited in Goodkin et al., 1992). Some personality traits predispose people toward active coping strategies and are, in turn, related to less distress. Two global personality constructs have been investigated in samples of people with HIV: optimism (Scheier & Carver, 1987) and hardiness (Kobasa, Maddi, & Kahn, 1982). Optimism has been associated with lower levels of distress, using positive attitudes, less avoidance of other people, and fewer AIDS-related concerns (Taylor et al., 1992). Research using the Kobasa hardiness scale has supported the benefits of hardiness in individuals with HIV. The hardiness scale includes a commitment to work and others subscale, a tendency to view stressors as challenges subscale, and an internal control subscale. Although there have been failures to replicate (Blaney et al., 1991), the Kobasa commitment subscale was related to hopefulness in people with HIV (Rabkin, Williams, Neugebauer, Remien, & Goetz, 1990), and the overall hardiness scale predicted decreased distress (Zich & Temoshok, 1987). Having a sense of control over the HIV infection appears to promote better mental and physical health outcomes (Rabkin et al., 1990; Solomon & Temoshok, 1987). People develop a variety of strategies for maintaining a sense of control. Patients with diseases such as cancer and AIDS often realize that they cannot control whether they become cured (Taylor, Helgeson, Reed, & Skokan, 1991). To maintain a sense of control, people with chronic disease often switch the arena in which they perceive control. They focus on controlling their daily symptoms and influencing the medical care they receive (Taylor et al., 1991). Data suggest that the development of a subjective sense of control over daily events and symptoms is helpful. PWAs exhibiting a stronger belief in their own control over the course of daily life and over the degree of subjective physical discomfort display less overall distress (Reed, Taylor, & Kemeny, 1993; Taylor et al., 1991; Thompson, Nanni, & Levine, 1994). PWAs with a greater sense of control also enjoy longer survival time (Solomon & Temoshok, 1987). In terms of its impact on distress, optimism does appear to be a useful coping strategy (Taylor et al., 1992). Coping mechanisms that protect against subjective vulnerability (feelings associated with learned helplessness) can be useful. Distress and vulnerability can vitiate immune system functioning (Mater et al., 1994). Lest the immune system be further depressed, PWAs should attempt to avoid feelings of vulnerability. Perhaps denial, a defensive strategy for reducing anxiety and subjective vulnerability, might have a salubrious impact. There is support for the idea that some forms of denial are helpful for people with HIV. PWAs who refuse to think about the disease, who go out more socially, and who joke about it (and their illnesses) display better mood (Namir et al., 1987). High scorers on a test of AIDS-specific optimism (which includes such items as "I feel safe from AIDS because I've developed an immunity" and "A person can be exposed to AIDS and successfully eliminate the virus from the body") are less distressed and are more likely to seek out social support (Taylor et al., 1992). High scorers on a distraction scale (which includes such items as "I try to keep it from bothering me," "I go out more socially," "I refuse to think about it," and "I work on trying to solve problems that my illness had brought on") use more active coping skills and score higher on dispositional optimism (Littrell, Diwan, & Bryant, 1996). Whereas some forms of denial have been associated with better outcome, mixed findings are obtained with regard to denial in the sense measured by the COPE denial scale (Carver, Scheier, & Weintraub, 1989). The COPE denial scale includes the following four items: "I refuse to believe that it has happened," "I pretend that it hasn't happened," "I act as though it hasn't ever happened," and "I say to myself this isn't real." Ironson et al. (1994) found that high scores on the COPE denial scale predicted faster AIDS disease progression. For the short term, however, the COPE denial scale may be associated with better functioning. Antoni, August, et al. (1990) found that those who use denial (as measured by the COPE) as a defense mechanism are less immunosuppressed on being informed of their seropositive status. The research findings on denial as a coping mechanism have been mixed. The mixed findings are probably attributable to conceptual categories that lump together diverse behaviors (for example, distraction and the COPE's denial operationalizations) that do not belong together in terms of their actual cooccurrence. Taylor, Collins, Skokan, and Aspinwall (1989) drew a distinction between optimism and denial. Those high in denial refuse to acknowledge threat or problem solve in the area of the threat. In contrast, optimists acknowledge threat and problem solve about ways to reduce threat. The coping mechanisms of optimists occur after they acknowledge the threat. The threat is interpreted in the most favorable way, minimizing the negative consequences predicted to result. Hence, denial defined as refusal to acknowledge threat can be distinguished from optimism. Littrell et al.'s (1996) findings suggest that distraction constitutes yet another form of coping that is conceptually distinct from denial and optimism. The opposite of denial is probably realistic acceptance and willingness to experience negative feelings. Some findings suggest that realistic acceptance may not be a useful strategy for people with HIV. Decreased survival time has been noted among those exhibiting greater realistic acceptance of the disease (Reed, Kemeny, Taylor, Wang, & Visscher, 1994). Focusing on or venting negative emotions predicts (albeit at marginal, p = .07 levels) lower natural killer cell activity (Goodkin et al., 1992). Informal observations by clinicians are consistent with the conclusions presented in the literature. Haney (1988), a social worker who himself lived with AIDS, reported that the worst thing a physician can do is to tell the patient that there is nothing that can be done and to provide an estimate on longevity. Haney suggested that a profitable focus is learning to live with AIDS and eschewing the role of victim. Some clinicians have expressed concern that denial of the threat of AIDS might result in risky behavior and the attendant transmission of the disease (Rosenberger & Wineburgh, 1992). The findings on this issue are mixed. Taylor et al. (1992) found that among people with HIV, those who were high in AIDS-specific optimism were not more likely to engage in high-risk sexual activity. Rather, a fatalistic attitude was related to having more sex partners. Taylor et al.'s results were consistent with Kelly et al.'s (1995) finding that higher perceived probability of contracting AIDS was associated with higher levels of unprotected sex in a cohort of gay men. Kelly et al.'s (1995) findings are counterintuitive. A more expected finding is that of Bauman and Siegel (1987), who reported that gay men who more frequently participated in unsafe sex more often underestimated the risk associated with anal receptive sex with a limited number of partners. Similarly, Folkman, Chesney, Pollack, and Phillips (1992) found that gay men who achieved higher scores on their positive reappraisal scale (endorsing greater reliance on prayer, finding a new faith, and changing and growing as a person) were more likely to engage in unprotected anal intercourse. Viewed collectively, although the research findings of Taylor et al. (1992) suggest that an optimistic view when a person is infected will not be associated with risky sex, other investigators working with men not selected for HlV seropositivity have found that risky behavior is associated with a more optimistic view about potential dangers. IMPACT OF HEALTH CARE DELIVERY ON PSYCHOLOGICAL STATES Littrell (1994) pointed out that the concern to encourage optimism raises a dilemma for the health care delivery system. Encounters with physicians will remind the person with HIV of his or her ultimate demise. Vitiated optimism and enhanced anguish are dangers. Empirical findings consistent with this view are available. Being tested for HIV and learning of a seropositive status (Ostrow et al., 1989) can create distress. People fear being tested, anticipating an inability to cope (Lyter, Valdiserri, Kingsley, Amoroso, & Rinaldo, 1987), and in fact learning of seropositivity does increase suicidal ideation (Pergami, Gala, Burgess, Invernizzi, & Catalan, 1994). Beyond bad feelings, evidence suggests that the process of testing and learning of a seropositive status can suppress immune function (Ironson et al., 1990). Early treatment too has potential for creating distress. In groups receiving preventive AZT (zidovudine) treatment, greater distress (Jacobsen, Perry, Hirsch, Scavuzzo, & Roberts, 1988) and greater realistic acceptance of disease have been noted (Reed et al., 1994). Perhaps the greater distress found in those receiving early treatment is attributable to decreased denial, attenuated optimism, or both. Of course, major gains can be achieved through early identification of the HIV virus, permitting, for example, interventions for delaying disease onset. The shorter longevity of women and African Americans with AIDS has been attributed to the fact that they have less access to health care than more affluent groups (Chaisson, Keruly, & Moore, 1995). Social workers should encourage HlV-infected individuals to seek health care. However, by recognizing the down side to the provision of health care, namely its psychological reminders of being an at-risk individual, social workers can respond by developing interventions to change the psychological impact of participating in the health care system. Evidence suggests that behavioral and psychological interventions can buffer the immune-suppressing effects of HIV testing. Both cognitive behavioral stress management and exercise training have documented efficacy in precluding the immunosuppressive effects of being tested for HIV (Esterling et al., 1992; LaPerriere et al., 1990). Although the impact of additional interventions on people with HIV has yet to be demonstrated, the salubrious effects of a range of interventions seems promising. A wide range of choices are available in structuring social work interventions for people with HIV. Coupling social work visits with medical care appointments may help change the subjective impact of health care visits. Rather than feeling demoralized as a result of being reminded that one has a fatal disease, PWAs might be encouraged to focus on garnering social support and honing useful coping skills for the impending week. Social workers can provide services in the form of groups or individual interventions. With cancer, another disease whose progression is probably dependent on immune system functioning, group therapy has been shown to increase longevity (Spiegel, Bloom, Kraemer, & Gottheil, 1989) as well as enhance the activity of particular arms of the immune system (Fawzy et al., 1990). Group interventions for PWAs may have a real advantage over individual sessions. In general samples, social support has been found to be associated with increased longevity (Berkman & Syme, 1979; House, Robbins, & Metzner, 1982) and diminished susceptibility to immune suppression (Kiecolt-Glaser et al., 1984). The importance of social support as a factor associated with decreased distress has been demonstrated in people with HIV as well (Blaney et al., 1991; Fleishman & Fogel, 1994; Hays, Catania, McKusick, & Coates, 1990; Rabkin et al., 1990; Zich & Temoshok, 1987). People with HIV may, as a group, encounter greater obstacles in gaining access to social support. Over half of PWAs have limited contact with their families of origin (Namir, Wolcott, & Fawzy, 1989). Many report feelings of isolation (Wolcott, Namir, Fawzy, Gottlieb, & Mitsuyasu, 1986). Group therapy, allowing for a broader range of support, may be the optimal vehicle for providing services. Unstructured group sessions, as opposed to structured sessions, have been found to increase anxiety and produce more treatment attrition (Fawzy, Namir, & Wolcott, 1989; Solomon & Temoshok, 1987). Littrell (1994) enumerated a variety of potential foci for structuring group activities. These foci include the following: teaching problem solving coping skills. Fawzy, Fawzy, and Pasnau (1991) offered a specific format incorporating the use of photographs of individuals who are using both poor and good coping skills. These photographs can be used as points of departure for group discussion. teaching relaxation training. Relaxation has been demonstrated to enhance immune system functioning among elderly people (Kiecolt-Glaser et al., 1985). teaching skills for obtaining health care and social security disability entitlement and for exercising one's rights under the Americans with Disabilities Act of 1990 end the Fair Housing Act. developing strategies for informing friends and family about one's health status. developing strategies for decreasing unprotected sex,which, along with infecting others, can increase the risk of secondary infections that can activate the AIDS virus (Esterling et al., 1992). Shernoff's (1990) program for eroticizing protected sex might be successfully incorporated into such strategies. The literature on relapse prevention (Littrell, 1991) might also be of use in decreasing lapses into risky behavior among those who are committed to safe sex. developing strategies for decreasing alcohol consumption. Alcohol use is associated with immune system suppression in PWAs (Goodkin et al., 1992). increasing a sense of control. Perlmuter and Langer (1982) found that enhancing the salience of choices increases one's subjective sense of control. Thus, listing ways in which the individual has influenced events in the course of the day might be useful to augment subjective control. Social workers should develop treatment interventions for people with HIV that discourage feelings of helplessness and encourage feelings of competence, efficacy, and optimism. Knowing that one is infected with HIV is inherently disheartening. 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Accepted May 26, 1995 ~~~~~~~~ By Jill Littrell Jill Littrell, PhD, LCSW, is assistant professor, Georgia State University, 2436 Northlake Court, Atlanta, GA 30345-2226. e-mail: littrell@gsu.edu Copyright of Health & Social Work is the property of National Association of Social Workers and its content may not be copied without the copyright holder's express written permission except for the print or download capabilities of the retrieval software used for access. This content is intended solely for the use of the individual user. Source: Health & Social Work, Nov96, Vol. 21 Issue 4, p287, 5p. Item Number: 9612032934 Word Count: 4227
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