Suicidality and Anxiety Sensitivity in Adults with HIV

Abstract

Suicide rates among HIV-positive individuals are more than three times higher than in the general population. Anxiety sensitivity (AS) may be clinically relevant to increasing our understanding of suicide among individuals with HIV. Specifically, relations between AS cognitive concerns and suicide related outcomes have been observed across a range of populations. The current investigation sought to examine the effect of AS and individual AS subfactors (i.e., cognitive, physical, and social concerns) in relation to suicidality in a sample of adults with HIV. Participants were 164 adults with HIV (17.1% women; mean age=48.40) recruited from AIDS service organizations in Vermont/New Hampshire and New York City. Findings from the current study indicate that AS cognitive concerns (β=0.46, p=0.001), but not the global AS factor, are positively associated with elevated rates of suicidality among persons with HIV above and beyond demographics, HIV relevant factors, and negative affectivity. There was also a negative trend for AS physical concerns in terms of suicidality (β=−0.25, p=0.07). Clinicians may benefit from implementing AS reduction strategies with HIV-positive persons who endorse elevated suicide risk as well as elevated AS cognitive concerns. The current study is limited by a cross-sectional design and lack of suicide attempt history. Future work would benefit from longitudinal examination of the observed relations, further inquiry regarding the relation between AS physical concerns and suicidality and a more comprehensive assessment of suicidality.

Introduction

S uicide results in 1 death every 40 sec worldwide and it is predicted that by the year 2020 the rate of suicide death will increase to 1 every 20 sec.¹ People living with HIV appear to be particularly vulnerable to suicidal ideation and suicidal behavior. Indeed, despite the development of antiretroviral therapy (ART), which has become a viable long-term treatment for HIV infection,² suicide rates among HIV-positive individuals remain more than three times higher than in the general population.³

Carrico⁴ has proposed that psychiatric, biologic, and social vulnerabilities interplay to confer elevated suicidality among HIV-positive individuals. As such, there are several empirical observations that exemplify suicide risk for persons with HIV. First, current estimates in the general population suggest that the overwhelming majority of those who die by suicide have a diagnosable mental health disorder.⁵ Among persons with HIV, there is a greater prevalence of comorbid psychiatric disorders than that observed in the general population.^6
–8 Consistent with the general population, among HIV populations, a diagnosis of mental illness and a history of psychiatric treatment have been significantly associated with death by suicide.³

Second, there are biologic factors unique to HIV-positive individuals that may also play a role in increased suicidality. For example, the chronic immune activation that is typical of HIV infection promotes the degradation of l-tryptophan, an important precursor to serotonin.⁴ This degradation has been associated with greater depressive symptoms among HIV positive individuals.^9,10 Moreover, certain symptoms of depression, including hopelessness, have been related to increased suicidal ideation among those with HIV.^11,12

Finally, the social stigma of living with HIV may also play a role in increasing suicidality. HIV disproportionately affects already highly stigmatized, at-risk groups (e.g., injection drug users, racial and sexual minorities).⁴ In addition, traditionally nonstigmatized groups (e.g., heterosexual men) with HIV actually perceive greater HIV stigma than sexual minorities with HIV,¹³ perhaps due to the association of HIV with already stigmatized groups (e.g., men who have sex with men). Being HIV positive is predictive of being subjected to antigay discrimination or violence, which in turn, is associated with increased suicidal ideation.¹⁴

Anxiety sensitivity (AS) is a well-researched cognitive vulnerability factor for certain psychiatric disorders that is potentially relevant to increasing our understanding of suicide among individuals with HIV. AS refers to fear of anxiety related sensations, and is associated with the development of a range of psychopathology including anxiety and mood disorders,^15,16 as well as substance use disorders.^17,18

An emerging body of research now suggests that AS is associated with suicide.^20,21 The relationship between AS and suicide has been elucidated by examining the subfactors of AS. AS is constituted from three lower order facets including physical concerns, cognitive concerns, and social concerns.²² A number of studies suggest that AS cognitive concerns, in particular, may be related to suicide.^20,21,23 AS cognitive concerns refer to fears of mental incapacitation or losing control of mental processes in the context of stress or anxiety symptoms. The association between AS cognitive concerns and suicide is consistent with recent positive feedback models of suicide suggesting that those vulnerable to catastrophic cognitions (“I might lose control of my mind”), such as individuals with high AS cognitive concerns, are at increased risk of attempting suicide.²⁴ The Katz et al.²⁴ model suggests that limbic-autonomic arousal and catastrophic thinking are mutually activating, thereby creating a positive feedback loop. Within this cycle, catastrophic ideation (e.g., high AS) becomes amplified over time, eventually producing suicidal ideation. According to this model, the combination of limbic-autonomic arousal and suicidal ideation drives an individual to attempt suicide in order to stop the escalating distress.²⁴

Emerging relations between AS cognitive concerns and suicide related outcomes have been observed across a range of clinical populations. AS cognitive concerns were significantly related to suicidal ideation in a sample of panic disorder patients,²³ and suicidal ideation and suicide attempt history in a large and diverse sample (n=1378) of clinical outpatients.²⁰ Recent work also suggests that high AS cognitive concerns in the presence of low AS physical concerns were significantly associated with suicide attempt history in clinic outpatients evidencing considerable posttraumatic stress disorder (PTSD) symptomatology.²¹ Additionally, AS cognitive concerns prospectively predicted increased suicidal ideation in a large sample of military cadets (n=1083) after undergoing basic training.²¹ Finally, AS cognitive concerns have been found to be associated with increased suicidality in two samples of cigarette smokers, a population at increased risk for death by suicide (unpublished data).

Given the consistent association between AS and suicidality, it is important to identify populations at risk for suicide related outcomes by virtue of elevated AS. Extant research indicates that persons with HIV may be one such population. Individuals with HIV experience a wide range of uncomfortable bodily sensations (e.g., muscle aches, tingling, nausea) as part of their illness and medications used to manage HIV.²⁵ These sensations are often distressing and significantly related to anxiety and depression.^25
–27 Recent empirical work has revealed that AS is significantly related to negative mental health outcomes among this population. For example, AS physical concerns are significantly associated with somatization symptoms, whereas AS cognitive concerns are significantly related to anxiety symptoms above and beyond negative affectivity and gender.²⁸ In addition, AS is significantly related to panic, social anxiety, and depression symptoms, and interacts with HIV-related symptom distress in terms of panic and social anxiety symptoms among persons with HIV. Specifically, individuals with high AS and HIV-symptom distress may be at greatest risk for panic and social anxiety symptoms.²⁹ Despite these notable findings, there are still a number of gaps in the HIV–suicide literature. Primarily, constructs such as AS in general and the AS cognitive concerns subfactor specifically need to be evaluated in relation to suicide in this population. In fact, no studies of elevated suicidality among those with HIV have examined the contribution of any malleable anxiety related factor. Such work is needed given the elevated rates of anxiety among this population³⁰ and recent reports that 70% of those who attempt suicide have an anxiety disorder.³¹ Second, in most previous work focusing on the AS cognitive concerns-suicide interrelation,^20,21,23 the Anxiety Sensitivity Index³² was used to measure AS cognitive concerns. Newer measures of AS such as the Anxiety Sensitivity Index-3 (ASI3)³³ that have been designed to more accurately measure the AS subfactors would likely provide an even better assessment of the relations between AS and suicidality. Finally, measurement of suicidality in the majority of previous work has been done using a single item.^21,23 Utilization of more robust indicators of suicidality, covering a range of nonlethal suicide-related processes, is important to ensure the accuracy and meaningfulness of prior findings.

The aim of the current study was to address the current gaps in the suicide and HIV literature by examining the associated between AS (as measured by the ASI3) and a multi-item measure of suicidality³⁴ in a sample of HIV positive individuals. Based on previous findings,^20,21,23 we predicted that AS cognitive concerns would be significantly and incrementally associated with suicidality, above and beyond demographic and HIV relevant factors, negative affectivity, and shared variance with other AS subfactors.

Methods

Participants were eligible to participate if they were at least 18 years old, had a diagnosis of HIV/AIDS, and had the mental capacity to give informed written consent, which was assessed by the ability to read through the consent form and explain the study purpose. No participants were excluded from participation. Of note, one participant's data was not included in the analyses because the response pattern was indicative of random responding (i.e., endorsed the same value on every item on each questionnaire).

Measures

Demographic (e.g., age, gender, race/ethnicity, sexual orientation) and medical information, including participant HIV/AIDS status, disease stage (indexed by most recent CD4⁺ T cell count), and month and year of diagnosis were self-reported by participants.

Positive and Negative Affect Scale (PANAS).³⁵

Trait-like negative mood was assessed using the well-established 20-item PANAS. For each of 20 adjectives (e.g., “irritable”), participants indicate on a 5-point Likert-type scale (1=very slightly to 5=extremely) the degree to which the descriptor typifies how they generally felt during the past year. Only the negative affectivity scale (PANAS-NA) was used in this study as a global index of the trait-level propensity to experience negative affect symptoms. The PANAS-NA has demonstrated excellent internal consistency in clinical and non-clinical populations (range of alpha coefficients: 0.85 to 0.93), test–retest reliability (e.g., r=0.71 for 2 months to r=0.43 for 72 months), as well as convergent and discriminant validity in relation to multiple measures of state-level affect, trait-level mood, and personality.³⁶ The PANAS-NA evidenced good internal consistency among the present sample (Cronbach α=0.89).

Anxiety Sensitivity Index-3 (ASI-3).³³

The ASI-3 is an 18-item measure on which respondents indicate, on a 5-point Likert-type scale (0=very little to 4=very much), the degree to which they fear the potential negative consequences of anxiety-related symptoms and sensations (e.g., “It scares me when my heart beats fast”). The sum of all item responses yields the total ASI score, which ranges from 0 to 72. The ASI-3 has demonstrated good psychometric properties.^33,37 The ASI-3 is composed of one higher-order factor (AS-Total) and three lower-order factors: physical, cognitive, and social concerns.³³ The ASI-3 demonstrated high levels of internal consistency in terms of the total score (Cronbach α=0.95) and individual subscales (AS cognitive α=0.93, AS-physical α=0.90, AS-social α=0.83) among the present sample.

Inventory of Depression and Anxiety Symptoms (IDAS).³⁴

The IDAS is a 64-item measure that assesses symptom dimensions of depression and anxiety disorders. The IDAS contains 10 specific symptom scales: suicidality, lassitude, insomnia, appetite loss, appetite gain, ill temper, well-being, panic, social anxiety, and traumatic intrusions, and, two broader scales: general depression and dysphoria. The IDAS subscales have demonstrated sound internal consistency across multiple clinical and nonclinical populations (range of α coefficients: 0.72 to 0.92), test–retest reliability (e.g., r=0.79 for 1 week) as well as convergent and discriminant validity in relation to the multiple measures of depression and anxiety.³⁴ In the current study, the suicidality subscale, which is composed 6 items (e.g. “I had thoughts of suicide,” “I hurt myself purposely”) was used to assess suicidal ideation and demonstrated good internal consistency among the present sample (Cronbach α=0.86).

Procedure

Participants were recruited from AIDS service organizations (ASOs) and hospital-based medical clinics in Vermont and New Hampshire, and one ASO in New York City (NYC). Slightly more than half of the participants (58.5%) were recruited from NYC. Interested persons contacting the university research clinic or the ASO in NYC, and who self-reported having a diagnosis of HIV or AIDS, were scheduled for an in-person appointment. Participants were then told that they would be asked to report their most recent CD4⁺ T cell count and viral load at the appointment (to reduce error in reporting). Eligible persons came into the research clinic or their ASO and were informed about the study. After consenting to participate, participants completed a battery of self-report measures and were compensated $25 for their time. This study was approved by the Institutional Review Board of the University of Vermont.

Data analytic strategy

Descriptive statistics and bivariate correlations among study variables were first examined. Hierarchical regression analyses were subsequently conducted with the suicidality subscale of the IDAS as the outcome variable. Age, gender, race/ethnicity, sexual orientation, recruitment site, CD4 T cell count, and years since HIV diagnosis were entered at step 1. Negative affectivity was entered at step 2. At step 3 the ASI-3-total score was entered in one model and the ASI-3 subscales were entered as a block in a second model to test the specificity of AS cognitive concerns.

Results

Participants

Participants included 164 adults (Mage=48.40, standard deviation [SD]=9.57, observed range=19–73; 17.1% female) with HIV/AIDS. The racial/ethnic distribution of the sample was 40.9% white/Caucasian, 31.1% black, 22.0% Hispanic, and 6.1% mixed/other (e.g., Native American, French, West Indian). Half of the sample identified as gay, 36.6% as heterosexual, and 12.2% as bisexual. The majority reported having at least a high school degree (69.5%); however, 75.6% reported being unemployed. Accordingly, more than half (56.7%) reported an annual income less than or equal to $10,000. Half of the participants reported a diagnosis of HIV, while 47% reported a diagnosis of AIDS (3% did not respond). On average, participants reported living with HIV for 15 years (M=15.23, SD=6.39). HIV transmission risk factors included men having unprotected sex with men (53.4%), sharing needles for injection drug use (14.7%), men having unprotected sex with women (14.1%), women having unprotected sex with men (8.6%), unknown (5.5%), blood transmission (2.5%), and born with HIV (1.2%).

Bivariate correlations

The AS total score and individual AS subscales were positively related to suicidality (AS total r=0.32, p<0.001; AS cognitive r=0.39, p<0.001; AS physical r=0.25, p=0.001; AS social r=0.20, p=0.02). The AS subscales were positively related to one another (range of observed r‘s=0.75 to 0.79, p<0.001). Negative affectivity was positively related to suicidality (r=0.41, p<0.001); however, the demographic and HIV-specific factors were not related to suicidality at the bivariate level.

Hierarchical regression analyses

See Table 1 for a summary of hierarchical regression analyses. The first model, which examined the AS total score as the primary predictor variable, accounted for 26% of variance in suicidality. Control variables entered at step 1 accounted for 13% of variance (p=0.01), with gender (β=0.18, p=0.05) and race/ethnicity (β=0.25, p=0.008) making significant contributions to the model. At step 2, negative affectivity accounted for an additional 13% of variance ((β=0.37, p<0.001). At step 3, the AS total score did not account for any additional variance (ΔR ²=0.00, p=0.57).

Table 1.

Predictors of Suicidality

	ΔR²	t	β	sr²	p
Model 1
Dependent variable: suicidality ^a
Step 1	0.13				0.01
Age		−1.78	−0.16	0.02	0.08
Gender^b		1.97	0.18	0.03	0.05
Sexual orientation		0.50	0.05	0.00	0.62
Race/ethnicity		2.69	0.25	0.05	0.008
Recruitment site^c		1.27	0.12	0.01	0.21
CD4 T cell count		−1.35	−0.11	0.01	0.18
Years since HIV diagnosis		1.33	0.12	0.01	0.19
Step 2	0.13				<0.001
PANAS-NA^d		4.71	0.37	0.17	<0.001
Step 3	0.00				0.57
AS total^e		0.57	0.05	0.00	0.57
Model 2
Dependent variable: suicidality
Step 1	0.13				0.009
Age		−1.78	−0.16	0.02	0.08
Sex		2.04	0.19	0.03	0.04
Sexual orientation		0.55	0.05	0.00	0.58
Race/ethnicity		2.76	0.25	0.05	0.007
Recruitment site		1.15	0.11	0.01	0.25
CD4 T cell count		−1.26	−0.11	0.01	0.21
Years since HIV diagnosis		1.37	0.12	0.01	0.17
Step 2	0.11				<0.001
PANAS-NA		4.43	0.35	0.13	<0.001
Step 3	0.06				0.01
AS cognitive^e		3.37	0.46	0.08	0.001
AS physical^e		−1.85	−0.25	0.03	0.07
AS social^e		−1.24	−0.16	0.01	0.22

Inventory of Depression and Anxiety Symptoms.³⁴

Gender coded as 1=male 2=female.

Recruitment site coded as 1=Vermont/New Hampshire 2=New York City.

Positive and Negative Affect Scale-Negative Affectivity (PANAS-NA).³⁵

Anxiety Sensitivity Index-3.³³

The second model, which examined the AS subscales as the primary predictor variables, accounted for 31% of variance in suicidality. The addition of the AS subscales at step 3 of the model accounted for 6% of unique variance (p=0.01) with AS cognitive concerns as the sole predictor of suicidailty (β=0.46, p=0.001). There was also a negative trend for AS physical concerns in terms of suicidality (β=−0.25, p=0.07).

A third model examining the interaction between AS cognitive concerns and AS physical concerns in terms of suicidality was explored. There was not a significant interaction above and beyond the covariates at step 1 and main effects at step 2.

Discussion

The findings from this study indicate that AS cognitive concerns are associated with elevated rates of suicidality among persons with HIV. These results add to a growing body of literature linking AS cognitive concerns and increased risk of suicide-related outcomes.^20,21,23 In contrast, the global AS factor was not significantly associated with elevated suicidality in this sample. This finding is consistent with a study examining the effect of AS on suicidality among cigarette smokers (unpublished data), but not with a study examining the AS and suicide association in a large and diverse clinical outpatient sample.²⁰ Such findings suggest that examining AS as a unitary construct among persons with HIV may obscure relationships between AS subfactors (e.g., AS cognitive concerns) and suicide.

Our findings add to an emerging literature that suggests certain anxiety constructs are associated with elevated suicidality.^31,38 The results of the present investigation implicate AS cognitive concerns as a mechanism that may partially account for increased suicide risk among HIV positive individuals, a population at increased risk for death by suicide.^3,39 This finding adds to previous AS-HIV research indicating the AS cognitive concerns is particularly relevant for anxiety symptoms.²⁸ Fortunately, AS is amenable to significant amelioration utilizing very brief interventions. These interventions feature corrective psychoeducation and interoceptive exposure exercises and have been found to reduce total AS as well as AS subfactors, including AS cognitive concerns.^18,40 Clinicians may benefit from implementing these AS reduction strategies with HIV-positive persons who endorse elevated suicide risk as well as elevated AS cognitive concerns; however, future work is needed examine the effects of reducing AS in terms of suicidality reduction. Unexpectedly, AS physical concerns were trending toward a significant negative association with suicidality within the regression model. Although this was not predicted in the current study, this is partially consistent with previous findings that suggest AS physical concerns may have a protective effect against attempting suicide.²¹ This association is consistent with the interpersonal-psychological theory of suicide which posits that an individual acquires the capability to enact lethal self-injury through accumulation of painful and provocative life experiences.^41,42 Individuals with high AS physical concerns report thoughts such as “It scares me when my heart beats rapidly” and “It scares me when I feel shaky.” These individuals seem unlikely to seek out the painful and provocative experiences proposed by the interpersonal-psychological theory as essential in acquiring the capability for suicide. Further, the overall global AS factor (which predominantly measures AS physical concerns) is associated with pain-related fear and avoidance.⁴³ Given that individuals with HIV are particularly prone to many physical symptoms as a result of the virus and medication side effects (e.g., fatigue, gastrointestinal problems, pain),^25
–27 future work is needed to further examine the relation between AS physical concerns and suicidality, perhaps within more complex models involving perceptions of pain and HIV-related symptoms. It is important to note a few limitations of the present study. First, it is possible that the association between AS cognitive concerns and suicidality may not generalize to suicide attempts or actual death by suicide. Future work is needed to examine the relations between AS cognitive concerns and history of suicide attempts among people with HIV; especially since extant empirical work indicates that a nonfatal suicide attempt is the strongest predictor of death by suicide.⁴⁴ This work is particularly important in terms of extending the current findings and aiding in support for AS reduction as part of suicide prevention. Second, the cross-sectional design of the current study precludes us from examining the causal roles of AS subfactors in suicidality among HIV-positive persons. Future research would benefit from examining AS-suicide associations prospectively to better understand the temporal relations and risk. Last the current study was limited to examining the main effects of one, albeit clinically relevant, vulnerability factor (i.e., AS) for suicidality. Future work would benefit from the examination of other vulnerability factors for suicidality among persons with HIV and plausible mediating and moderating variables. For example, recent findings highlight the importance of assessing for domestic violence in terms of suicidality.⁴⁵

The growing body of evidence suggests that AS cognitive concerns play a significant role in elevated suicidality across many different populations at risk for death by suicide, including persons with HIV. However, future work needs to examine this relationship prospectively, as well as designing interventions that reduce AS cognitive concerns in populations at elevated risk for death by suicide.

Footnotes

Acknowledgments

This project was funded by a McNeil Prevention and Community Psychology grant awarded to Dr. Gonzalez and a University of Vermont Undergraduate Research Endeavors Competitive Award granted to Mr. Parent. We also acknowledge recruitment efforts by AIDS Service Organizations in Vermont and New Hampshire and by Michael Hickey, LMSW at Village Care in New York City.

Author Disclosure Statement

No competing financial interests exist.

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, Gish

, Gill

. Domestic violence screening: Prevalence and outcomes in a Canadian HIV population. AIDS Patient Care STDs, 2010; 24:763–770.

Suicidality and Anxiety Sensitivity in Adults with HIV

Abstract

Introduction

Methods

Measures

Positive and Negative Affect Scale (PANAS). 35

Anxiety Sensitivity Index-3 (ASI-3). 33

Inventory of Depression and Anxiety Symptoms (IDAS). 34

Procedure

Data analytic strategy

Results

Participants

Bivariate correlations

Hierarchical regression analyses

Discussion

Footnotes

Acknowledgments

Author Disclosure Statement

References

Positive and Negative Affect Scale (PANAS).³⁵

Anxiety Sensitivity Index-3 (ASI-3).³³

Inventory of Depression and Anxiety Symptoms (IDAS).³⁴