CHAPTER 8: ANXIETY DISORDERS IN PATIENTS WITH HIV/AIDS

Anxiety is a common symptom in HIV-infected patients. When anxiety symptoms are

severe or persistent, patients may have an anxiety disorder. These disorders include panic
disorder, generalized anxiety disorder, obsessive-compulsive disorder, and post-traumatic
stress disorder (PTSD) (see Chapter 9: Trauma and Post-Traumatic Stress Disorder in
Patients With HIV/AIDS). A recent study has shown that among HIV-infected patients
receiving medical care, 20.3% have an anxiety disorder, with 12.3% meeting the criteria
for panic disorder, 10.4% for PTSD, and 2.8% having generalized anxiety disorder.1
Patients with other psychiatric disorders, such as adjustment disorders, major depression,
psychosis, or substance use disorders, can also present with significant anxiety. To help
patients receive optimal care, clinicians need to be aware of the differences among these
specific disorders. Furthermore, patients with histories of anxiety or mood disorders are
susceptible to recurrence of anxiety symptoms during the course of HIV illness.

Key Point:
Patients with limited social support may be particularly susceptible to developing
anxiety symptoms.

I. CLINICAL PRESENTATION
RECOMMENDATION:
Clinicians should consider the diagnosis of an anxiety disorder when a patient
presents with common somatic symptoms, such as chest pain, diaphoresis, dizziness,
gastrointestinal disturbances, and/or headache, for which no underlying medical
etiology can be established.
Anxiety can present with a wide range of physiological manifestations, such as shortness
of breath, chest pain, racing/pounding heart, dizziness, diaphoresis, numbness or tingling,
nausea, or the sensation of choking. When patients present with these somatic symptoms,
for which no underlying medical etiology can be established, clinicians should consider
an anxiety disorder as the cause. In addition to somatic complaints, patients with anxiety
disorders often present with fear, worry, insomnia, impaired concentration and memory,
diminished appetite, ruminations, compulsive rituals, and avoidance of situations that
make them anxious.
The following questions may help clinicians determine whether anxiety is present:
Are you anxious?
Are you fearful or afraid?
Do you worry a lot?
Are you tense or irritable?
Are you restless?
Do you have difficulty sleeping?
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II. DIAGNOSIS
A. Diagnosis
Anxiety symptoms such as worry, nervousness, fear, and tension are commonly
experienced by people with HIV during periods of their illness and may be a response to
stressful situations. An anxiety disorder occurs when symptoms:
Interfere with a patients daily function (e.g., the patient is unable to work, leave
home, attend to medical care)
Interfere with personal relationships
Cause marked subjective distress
Even brief episodes of anxiety, such as those occurring during a panic attack, may
interfere markedly in a patients life and may warrant a diagnosis of an anxiety disorder.
B. Differential Diagnosis
1. Other Mental Health Disorders and Medical Conditions
RECOMMENDATIONS:
Clinicians should exclude other mental health disorders in patients who present
with anxiety.
Clinicians should exclude medical conditions, including HIV-related central nervous
system disease, in patients who present with anxiety.
Clinicians should review medication regimens and substance use history in patients
with anxiety.
Anxiety-like symptoms may also be caused by mental health disorders other than anxiety
disorders. For example, it may be difficult to distinguish depression with agitation from an
adjustment disorder with anxious mood. In general, adjustment reactions follow a stressful
event, which is often not true in clinical depression, and are less likely to present with the
entire vegetative symptom complex seen in depression, which is characterized by insomnia,
diminished appetite, diurnal variation in mood, loss of pleasure/interest, feelings of guilt,
fatigue, and attention and concentration problems.
Underlying medical conditions may also cause anxiety-like symptoms. Clinicians should
exclude medical etiologies when evaluating patients who present with these symptoms.
Patients can present with anxiety-like symptoms due to any one of the following conditions:

CNS pathologies: HIV-related infections, neoplasms, dementia, or delirium

Systemic or metabolic illness: hypoxia, sepsis, electrolyte imbalance
Endocrinopathies: thyroid disease, hypoglycemia, pheochromocytoma, Cushings
syndrome
Respiratory conditions: pneumonia
Cardiovascular conditions: arrhythmias, pulmonary embolus
Substance intoxication/withdrawal: from alcohol, nicotine, caffeine, cocaine, and
amphetamines
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In addition, psychotropic medications and other commonly prescribed medications may

cause anxiety-like symptoms (see Table 1). Intoxication or withdrawal from substances
such as alcohol, nicotine, caffeine, cocaine, and amphetamines can also cause anxiety.

Table 1
Medications That May Cause Anxiety-Like Symptoms in HIV-Infected Patients
Category

Medication

Antihypertensives

Reserpine
Hydralazine

Antituberculous agents

Isoniazid
Cycloserine

Psychotropics

Most antipsychotic and antidepressant medications.

Bupropion, an antidepressant that is also given for
smoking cessation, makes some patients extremely
anxious.

Sympathomimetics

Ephedrine
Epinephrine
Dopamine
Phenylephrine
Phenylpropanolamine
Pseudoephedrine

Antiretrovirals

See the Adult HIV Guidelines, Chapter 4A:

Antiretroviral Therapy, Appendix A

Other

Amphetamine and methylphenidate

Digitalis
Lidocaine
Monosodium glutamate
Nicotinic acid
Procarbazine
Steroids
Theophylline and aminophylline
Thyroid preparations

2. Anxiety Disorders
Once an underlying medical etiology or substance/medication-induced cause has been
excluded, a structured approach is helpful in distinguishing among the anxiety disorders
(see Figure 1).

Anxious?

Yes
Anxiety likely
due to a
general
medical
condition,
substance, or
medication

Underlying medical, substance, or medication etiology?

Yes

No

Discrete episodes of intense

anxiety/fear with chest pain,
pounding heart, diaphoresis,
shortness of breath?

Yes

Panic attacks
or panic
disorder

Fear/avoidance of
certain situations,
places, or objects?

Yes

Phobias

Worrying/
ruminating about a
variety of things for
months or years?

Intrusive, disturbing
thoughts or
compulsive rituals?

Yes

History of a traumatic event

continuing to cause great
distress?

Yes

Generalized
anxiety
disorder

Obsessivecompulsive
disorder

Figure 1. Algorithm for distinguishing anxiety disorders.

Yes

History of a stressful
situation
causing nervousness
or upset?

Yes

Event <1
month ago

Symptoms
>1 month

Acute
stress
disorder

PTSD

Adjustment
disorder with
anxious
mood

III. MANAGEMENT OF HIV-INFECTED PATIENTS WITH ANXIETY DISORDERS

RECOMMENDATION:
Clinicians should refer patients with symptoms of anxiety to a psychiatrist for
evaluation and possible ongoing treatment when:
Anxiety symptoms do not respond to standard pharmlogic treatment or
basic supportive/behavioral interventions
The diagnosis of an anxiety disorder is difficult to establish
Anxiety is persistent or severe
Patients with obsessive-compulsive disorder have intrusive or disturbing
thoughts or compulsive rituals that are poorly controlled with the current
medication or that cause the patient marked subjective distress
Anxiety occurs in patients with a significant substance use history or in those
who are actively using substances

A. Psychological/Supportive Intervention in the Primary Care Setting

Certain anxiety symptoms can be effectively managed without the use of medication.
There are also patients who prefer to avoid the use of psychotropic medication. Patients
with mild anxiety symptoms that do not interfere with function may respond to
supportive or behavioral interventions. Clinicians may find the following strategies
helpful in such situations:
Expressing empathy
Educating patients about anxiety
Reassuring patients that anxiety is the cause of somatic symptoms experienced
during panic attacks
Identifying the psychological factors that contribute to anxiety
Preparing patients for stressful situations and assisting in development of coping
mechanisms
Teaching patients simple relaxation exercises. Slow, deep breathing with focus on
inspiration and expiration of air can be helpful. Such exercises can be useful when
patients practice for 1 minute three times a day, increasing to 5 minutes, if
possible.

Key Point:
Basic supportive and behavioral interventions are sufficient to alleviate anxiety in certain
patients.

For patients with more severe anxiety, psychotherapy, specialized behavioral treatments
such as cognitive-behavioral therapy, and/or medication may be required.

B. Pharmlogic Intervention in the Primary Care Setting

RECOMMENDATION:
Clinicians should be familiar with the safety profiles of medications used to treat
anxiety and how these medications may interact with those used in the treatment of
HIV disease (Appendix I).
HIV-infected patients, especially those who are symptomatic, are more sensitive to
medication side effects and may respond to lower dosages of anxiolytics. For these
reasons, it is generally best to start low and go slow when prescribing medication.
Furthermore, because patients are often receiving multiple medications, the potential for
drug-drug interactions is great. Clinicians should be familiar with the safety profiles of
medications used to treat anxiety and how these medications may interact with those used
in the treatment of HIV disease (Appendix I).
1. General Principles in the Pharmlogic Treatment of Anxiety Disorders and Their
Symptoms
No single medication will treat the spectrum of symptoms seen in patients with anxiety
disorders. The following general principles will help determine the pharmlogic intervention
that is most likely to be helpful (see Table 2).

Panic Attacks/Panic DisorderIn general, while symptomatic relief for patients

experiencing panic attacks can usually be accomplished with the short-term use of
benzodiazepines, selective serotonin reuptake inhibitors (SSRIs) are the treatment of
choice because they effectively prevent panic attacks from recurring. Given the
morbidity associated with ongoing panic attacks, it is important to give prophylaxis to
prevent recurrence. Venlafaxine is also effective in preventing panic attacks, as well
as the tricyclic antidepressants, but the latter are limited in their usage due to their
side-effect profiles and potential for drug-drug interactions.
Generalized Anxiety DisorderPatients with chronic anxiety, consistent with
generalized anxiety disorder, may require long-term therapy with medication.
Buspirone should be considered because it is an effective anxiolytic that has no
potential for abuse, which is particularly important for patients with a history of
substance use. The SSRIs and venlafaxine can also be effective in some patients with
persistent anxiety. Although some patients may experience relief sooner, the onset of
action of buspirone (3-6 weeks) and SSRIs (2-4 weeks) may necessitate the shortterm use of benzodiazepines; however, these should be used with caution, because of
the potential for dependence in some patients.
Adjustment DisorderShort-term symptomatic relief may be helpful in some
patients. A time-limited use (2-4 weeks) of benzodiazepines prescribed on a daily or
as-needed basis can be effective.
Post-Traumatic Stress DisorderSee Chapter 9: Trauma and Post-Traumatic
Stress Disorder in Patients With HIV/AIDS.
InsomniaInsomnia is an important symptom to treat because it often causes
impaired daily function. If an underlying medical etiology or chemical cause has been
excluded, insomnia should almost always be considered a symptom of an underlying
psychiatric disorder (major depression, adjustment disorder, generalized anxiety
disorder, PTSD). Diagnosis and treatment of the underlying condition is essential and
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often results in resolution of the insomnia. Nonpharmlogic approaches to treating

insomnia should be tried before prescribing medications. See Chapter Somatic
Symptoms for recommendations on treating insomnia.

Table 2
Commonly Used Psychotropic Medications in the Treatment of Anxiety Disorders and
Anxiety Symptoms
Disorder or Symptom
Medication or Medication Class
Panic disorder
SSRIs
Citalopram
Paroxetine
Escitalopram
Fluoxetine
Sertraline
Tricyclics
Nortriptyline
Desipramine

Doxepin
Imipramine

Benzodiazepines
Lorazepam
Alprazolam

Clonazepam

Other

Venlafaxine

Generalized anxiety disorder

Buspirone
SSRIs (listed above)

Obsessive-compulsive disorder

SSRIs (listed above)

Other
Fluvoxamine
Clomipramine

Venlafaxine

Adjustment disorder with anxious

mood
Insomnia*

Benzodiazepines (listed above)

PTSD

SSRIs (listed above)

Major depression with significant

anxiety

SSRIs (listed above)

Benzodiazepines (listed above)
Other
Venlafaxine
Tricyclics (listed above)

Zolpidem
Benzodiazepines (listed above) and temazepam
Other
Trazodone
Doxepin

* Nonpharmlogic approaches should be attempted before treatment with medication. See Chapter Somatic
Symptoms.
Sertraline and paroxetine are the only FDA-approved medications for PTSD. However, all SSRIs (in the
same doses used for depression) are helpful in treating symptoms of depression and anxiety. See Chapter 9:
Trauma and Post-Traumatic Stress Disorder in Patients With HIV/AIDS.
See Chapter 6: Depression and Mania in Patients With HIV/AIDS.
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2. Treatment of Anxiety Disorders in Substance Users

RECOMMENDATIONS:
Primary care clinicians should coordinate with a psychiatrist and/or addiction
specialist when managing anxiety disorders among patients with substance use
disorders. A psychiatric evaluation of these patients should be performed.
Clinicians should discuss the long-term risks of dependence, withdrawal, and abuse,
as well as the intended course of treatment, with patients with substance use
disorders or a history of substance use disorders before benzodiazepines or other
controlled substances are used to treat an anxiety disorder.
Clinicians should make the decision to withhold benzodiazepines on a case-by-case
basis, weighing the risks and benefits for patients with substance use disorders.
The treatment of patients with anxiety who have a substance use history or who are
actively using substances poses a challenge for clinicians. Such patients are most
effectively managed when treatment is coordinated with a psychiatrist/addiction
specialist. Psychiatric evaluation should be recommended for such patients. In some
cases, clinicians should defer initiating treatment until the evaluation is completed.
Although most clinicians attempt to avoid the use of medications with potential for abuse,
such as benzodiazepines and other controlled substances, such treatment is indicated in
some clinical situations. In these cases, discussions about the long-term risks of
dependence, withdrawal, and abuse and the intended course of treatment are necessary
prior to initiation of medication. The decision to withhold benzodiazepines should be
made on a case-by-case basis, weighing the risks and benefits. Furthermore, the risk of
discontinuing or withholding benzodiazepines may have serious medical complications.
Documentation in the medical record of the decision-making process is essential to
ensure consistency and continuity of care. (See Chapter Substance Use and Mental
Health in HIV-Infected Patients.)

REFERENCE
1. Vitiello B, Burnam MA, Bing EG, et al. Use of psychotropic medications among
HIV-infected patients in the United States. Am J Psychiatry 2003;160:547-554.