Research to date has focused on depression and co-existing pain in HIV with relatively little attention devoted to the study of anxiety disorders and concurrent pain. We therefore examined the relationships among panic disorder, posttraumatic stress disorder (PTSD), major depression and pain in a US national sample of persons with HIV, controlling for key sociodemographic and clinical variables, including HIV disease status. The study sample comprised 1489 HIV+ individuals (representing 219 667 persons). In multivariate analyses, panic disorder showed a strong association with pain (β=−15.70; 99% confidence interval [CI]=−21.33 to −10.08; P<0.001), which was significantly greater than PTSD (P=0.002) but only marginally greater than major depression (P=0.02). Longitudinal analyses of the three psychological disorders revealed that increasing pain from baseline to follow-up (an approximately 6-month period) was associated with panic disorder only (relative risk ratio=2.18, 99% CI=1.02–4.69; P<0.01), after controlling for baseline pain scores, baseline HIV disease status and change in disease stage across time. We discuss specific mechanisms by which clinical anxiety and chronic pain may be mutually maintained in HIV+ individuals. Our findings suggest that panic disorder, as well as PTSD and major depression are associated with greater pain in HIV patients.
For persons with human immunodeficiency virus (HIV), the experience of pain has a significant negative impact on health-related quality of life (Lorenz et al., 2001). Recently, we found that 67% of the first nationally representative sample of adults with HIV reported experiencing pain during the prior 4 weeks (Dobalian et al., 2004). Thus, despite treatment advances, pain remains a considerable problem in HIV+ individuals (Breitbart et al., 1996b, Hewitt et al., 1997, Vogl et al., 1999 and Frich and Borgbjerg, 2000). HIV-related pain may derive from various sources, including the direct effects of HIV on the central or peripheral nervous system, immune suppression (e.g. opportunistic infections), treatments for HIV (e.g. anti-retroviral medications), various disorders associated with HIV (Hewitt et al., 1997), as well as factors unrelated to HIV disease or its treatment (Hewitt et al., 1997 and Del Borgo et al., 2001).
Pain in HIV has been linked with greater impairment in functioning, greater symptom distress (Breitbart et al., 1996a and Vogl et al., 1999), and increased psychological distress (Rosenfeld et al., 1996). Depression in particular, has often been associated with the presence and intensity of pain in HIV (Rosenfeld et al., 1996 and Evans et al., 1998). Posttraumatic stress disorder (PTSD) has also been linked to greater pain intensity and pain-related interference in HIV+ individuals (Smith et al., 2002). However, little attention has been paid to the potential impact of other anxiety disorders on pain in this population.
In HIV seronegative populations, panic disorder (PD) has demonstrated strong links to pain (Kuch et al., 1991 and Schmidt and Telch, 1997). PD is characterized by frequent, recurrent panic attacks (i.e. discrete episodes of intense fear and physiological arousal), together with persistent concern about, and/or significant interference due to, the attacks. Panic attacks may include pain symptoms (e.g. chest pain); pain may also act as a trigger for such attacks. PD has been linked to increased pain prevalence—roughly 40% of such patients have reported persistent pain (Kuch et al., 1991). Similarly, 48% of generalized anxiety disorder patients reported a history of chest pain, although one-third of these also experienced panic attacks (Carter and Maddock, 1992).
Recent national estimates indicate that over 12% of patients with HIV meet criteria for PD (Vitiello et al., 2003), which is two to three times the general population rate. To the authors' knowledge, no prior work has focused specifically on the association between PD and co-occurring pain in HIV. We sought to investigate this relationship in a national sample of persons with HIV, taking into account key sociodemographic and clinical factors, as well as comorbid depression and PTSD. We hypothesized that presence of PD would be associated with more self-reported pain as well as increasing pain across time. Because PD often co-occurs with depression and PTSD (Brown et al., 2001 and Tsao et al., 2002), and because these latter disorders have been shown to predict increased pain, we also explored the unique contribution of each disorder to the experience of pain in HIV.
