2. Triple Whammy—HIV, Mental Disorders, African Americans
Anxiety Disorders Among African Americans
Research conducted in the 1980s and 1990s as part of the National Institute of Mental Health’s Epidemiological Catchment Area (ECA) study indicated that the prevalence of anxiety disorders was comparable across racial groups. Particular types of anxiety disorders, however, appear to be more prevalent among African Americans, including social anxiety disorder and post-traumatic stress disorder. [Robins 1984, Smith 2002]
A potentially more significant finding from other studies is the incidence of under-diagnosis and misdiagnosis of anxiety disorders among African Americans, resulting in lack of treatment or even the prescription of inappropriate treatment. Bell and colleagues reported that the manifestation of anxiety disorders may differ among racial groups. [Bell 1984, Bell 1986] A key finding of these studies was that possible racial differences may exist in the manifestation of anxiety; 15.5% of African Americans reporting isolated sleep paralysis also suffered from panic disorder, suggesting that African Americans with panic disorder may present with primary complaints other than those typically reported by patients diagnosed with panic attacks.
An analysis by Paradis and colleagues of the routine diagnostic intake process in an inner-city outpatient psychiatric department found that anxiety disorders were significantly underdiagnosed in African Americans.[Paradis 1992] The researchers interviewed 100 patients presenting for intake screening, using the Anxiety Disorders Interview Scale-Revised (ADIS-R) [Dinardo 1988] (a lengthy, structured interview designed to assess anxiety symptoms and to assign DSM diagnoses) The interviewers reported that, using ADIS-R, nearly 25% of the 100 subjects were diagnosed with panic disorder, with 1 case of obsessive-compulsive disorder, 3 cases of PTSD, 1 case of GAD, and 2 cases of social anxiety. The outpatient staff had not identified any of these diagnoses.
Increasingly, PTSD is being recognized as an anxiety disorder having causes other than a patient’s exposure to combat—eg, personal and domestic stressors, including HIV disease, particularly HIV-infected females. In fact, some patients may perceive the diagnosis of HIV infection itself as a traumatic event, triggering PTSD. Several studies have demonstrated the negative effects of a diagnosis of PTSD on the health of HIV-positive patients. Boarts and colleagues found that patients with symptoms of PTSD were less likely to be adherent to HAART and to have detectable HIV-1 RNA levels. [Boarts 2006] Smith and colleagues reported that HIV-infected patients who met the diagnostic criteria for PTSD reported having significantly higher pain intensity and greater pain-related interference in performance of daily activities. [Smith 2002]