Positive Psychological Factors and Life Themes in Relation to Health Outcomes in Women Living with HIV.

BACKGROUND: This mixed methods study identified positive psychological factors and life themes expressed in autobiographical narratives of predominantly Black women living with HIV (WLWH) and investigated these in relation to depressive symptoms, antiretroviral therapy (ART) adherence (≥ 95% of time), and undetectable HIV viral load (VL) (< 80 copies/ml). METHOD: Ninety-eight WLWH from the Women's Interagency HIV Study Chicago site (M age = 45.3; 91% Black) narrated three autobiographical life turning points, reliably coded for positive factors and life themes. ART adherence, VL and depressive symptoms, assessed with Center for Epidemiologic Studies Depression Scale total score (TOT) including its four factors (negative affect (NA), positive affect (PA), somatic symptoms (SS), and interpersonal problems (IP)), were collected over two time points: concurrently with narratives and 6 months later. Composite scores across the two time points were used in all analyses. RESULTS: Ten positive psychological factors (gratitude, insight, compassion, meaning-making, acceptance, mindfulness, generativity, optimism, self-reliance, and benevolent God beliefs) and three positive life themes (health improvements, positive relationships, and accomplishments) were identified in narratives. Higher accomplishments, overall positive factors, insight, mindfulness, self-reliance, optimism, meaning-making, and acceptance related to lower depressive symptoms (TOT, NA, SS, or IP). Positive factors and life themes did not significantly relate to PA. Higher compassion related to higher ART adherence. Higher accomplishments related to undetectable VL independent of ART adherence. CONCLUSION: Findings that positive psychological factors and life accomplishments may relate to better health, especially to lower depression, potentially contribute to developing positive psychology interventions for Black WLWH.

Correction To: Past, present or future? Word tense and affect in autobiographical narratives of women with HIV in relation to health indicators.

The original version of the article contained a mistake. The author has inadvertently given incorrect grant number. The corrected Grant No. is U01-AI034993.

Past, present or future? Word tense and affect in autobiographical narratives of women with HIV in relation to health indicators.

This study examined how the expression of positive and negative affect words and word tense in autobiographical narratives of 98 HIV+ women, predominantly African American, predicted undetectable HIV viral load (UDVL), CD4+ cells/mm3 counts and antiretroviral therapy medication (ART) adherence assessed concurrently (T1) and at 3 to 9-month follow-up (T2). Logistic regressions revealed that higher past tense words predicted worse odds of UDVL, CD4+ cells/mm3 above 350 at T1, and worse odds of 95% ART adherence at T2. However, using both high past tense words and high positive affect words predicted better odds of CD4+ cells/mm3 > 350 at T2. Higher future tense words predicted better odds of CD4+ cells/mm3 > 350 at T1. Additionally, using both high present tense words and negative affect words predicted better odds of UDVL at T1. These findings provide preliminary evidence that the quality of affect expression significantly interacts with temporal context to relate to the health of women with HIV.

Abuse, nocturnal stress hormones, and coronary heart disease risk among women with HIV.

This study investigated the relationships among abuse, nocturnal levels of cortisol and norepinephrine (NE), and coronary heart disease (CHD) risk as measured by the Framingham risk score among women with human immunodeficiency virus (HIV). Participants (n = 53) from the Chicago Women's Interagency HIV Study (WIHS), a longitudinal prospective cohort study initiated in 1994, were enrolled in this study during 2012. At WIHS baseline and annual follow-up visits, women were asked about recent experiences of abuse. Summary variables captured the proportion of visits for which women reported recent (past 12 months) physical, sexual, and domestic abuse. Cortisol and NE were assayed in overnight urine samples and adjusted for creatinine levels. Recent abuse was not significantly associated with levels of cortisol, NE, or NE/cortisol ratio. However, higher NE/cortisol ratio was significantly related to higher CHD risk score, higher cortisol was significantly related to lower CHD risk score, and NE was not associated with CHD risk score. In addition, higher proportions of visits with recent sexual abuse, physical abuse, and domestic abuse were significantly related to higher CHD risk score. The association between abuse exposure and CHD risk in the context of HIV infection is likely complex and may involve dysregulation of multiple neurobiological systems. Future research is needed to better understand these relationships and prevention and intervention efforts are needed to address abuse among women with HIV.

Resilience Moderates the Association Between Childhood Sexual Abuse and Depressive Symptoms Among Women with and At-Risk for HIV.

Childhood sexual abuse (CSA) places women at risk for HIV infection and once infected, for poor mental health outcomes, including lower quality of life and depressive symptoms. Among HIV-positive and demographically matched HIV-negative women, we investigated whether resilience and HIV status moderated the relationships between CSA and health indices as well as the relationships among CSA, depressive symptoms, and health-related quality of life (HRQOL). Participants included 202 women (138 HIV+, 64 HIV-, 87 % African American) from the Women's Interagency HIV Study Chicago CORE Center site. Results indicated that in both HIV-positive and HIV-negative women, higher resilience significantly related to lower depressive symptoms and higher HRQOL. CSA related to higher depressive symptoms only for women scoring low in resilience. Interventions to promote resilience, especially in women with a CSA history, might minimize depressive symptoms and poor HRQOL among HIV-positive and HIV-negative women.

Critical consciousness, racial and gender discrimination, and HIV disease markers in African American women with HIV.

Critical consciousness, the awareness of social oppression, is important to investigate as a buffer against HIV disease progression in HIV-infected African American women in the context of experiences with discrimination. Critical consciousness comprises several dimensions, including social group identification, discontent with distribution of social power, rejection of social system legitimacy, and a collective action orientation. The current study investigated self-reported critical consciousness as a moderator of perceived gender and racial discrimination on HIV viral load and CD4+ cell count in 67 African American HIV-infected women. Higher critical consciousness was found to be related to higher likelihood of having CD4+ counts over 350 and lower likelihood of detectable viral load when perceived racial discrimination was high, as revealed by multiple logistic regressions that controlled for highly active antiretroviral therapy (HAART) adherence. Multiple linear regressions showed that at higher levels of perceived gender and racial discrimination, women endorsing high critical consciousness had a larger positive difference between nadir CD4+ (lowest pre-HAART) and current CD4+ count than women endorsing low critical consciousness. These findings suggest that raising awareness of social oppression to promote joining with others to enact social change may be an important intervention strategy to improve HIV outcomes in African American HIV-infected women who report experiencing high levels of gender and racial discrimination.

Distress and Satisfaction in Women Who Perceive that Their Male Partners Use Pornography: The Roles of Attitude, Religious Commitment and Conservative Religiosity.

Qualitative studies suggest that women's attitudes and religiosity have an important role in their experience of their male partners' pornography use, but these factors have not been adequately studied. The present study examined the contributions of perceived frequency of male partners' solitary pornography use (PFREQ), women's attitudes toward their partners' pornography use, conservative religiosity, and religious commitment to women's pornography-related distress, relationship satisfaction, and sexual satisfaction in women who reported they were married to or cohabitating with men who had used pornography in the prior 3 months (median frequency = 1-2 times/week). Participants were online research panel participants (n = 625), age mean = 44[SD = 13], diverse SES, 86% White. Partial correlations and multiple regressions, controlling for demographic variables and COVID-19-related stress, indicated that higher PFREQ and negative attitudes toward pornography were significantly associated with women's higher pornography-related distress, lower relationship satisfaction, and lower sexual satisfaction. Moderation analyses found that negative attitude amplified the negative association between PFREQ and relationship satisfaction, and conservative religiosity amplified the positive association between PFREQ and pornography-related distress. Neither attitude nor religious factors moderated the negative association between PFREQ and sexual satisfaction. Findings suggest that attitude, religious factors, and PFREQ are each important to consider in research and clinical contexts.

Exploring the Effects of the Mindfulness and Countering Emotional Behaviors Modules From the Unified Protocol on Dysregulated Anger in the Context of Emotional Disorders.

Dysregulated anger in the context of emotional (e.g., mood, anxiety, related) disorders is associated with treatment attrition and a lower likelihood of responding to extant treatments. Therefore, there is a need to identify the most effective skills for targeting this anger and prioritize their delivery in treatment with the hope of producing more potent interventions. The current study explored the specific effects of two treatment skills (mindfulness and countering emotional behaviors) in isolation and combination as interventions for dysregulated anger using single-case experimental design. Patients were randomized to a 2- or 4-week baseline with no intervention applied and then to the first treatment skill received. All patients subsequently completed the alternate treatment skill and 1 month of follow-up. Results suggested the first module had clinically meaningful effects for five patients and the second module produced incremental improvement for five patients. Visual inspection and effect sizes indicated mindfulness produced greater reductions in anger when delivered in isolation compared to countering emotional behaviors (d = 0.96, 0.33, for mindfulness and countering emotional behaviors, respectively). With regard to the second module, more patients (n = 4) experienced a reduction in anger in response to mindfulness than to countering emotional behaviors (n = 1); effect sizes indicated significant improvements in response to both modules (d = 0.83, 0.72, for mindfulness and countering emotional behaviors, respectively). Taken together, results suggest mindfulness may be a more efficacious intervention for anger than countering emotional behaviors. Implications of these results for addressing dysregulated anger in treatment are discussed.

The Costs of Silencing the Self and Divided Self in the Context of Physical Abuse, Racial/Ethnic Identity, and Medication Adherence in Women Living with HIV.

Racial/ethnic minority status and physical abuse history are risk factors for higher mortality rates and lower adherence to antiretroviral therapy (ART) in women living with HIV (WLWH) in the United States. The current study tested the hypotheses that minority status and physical abuse history might lead women to silence the self (minimize and hide thoughts and feelings in order to avoid relational conflict, loss, and/or abuse) as measured by the Silencing the Self Scale (STSS), and that STSS might mediate and moderate relationships of physical abuse and racial/ethnic minority status with ART adherence. Divided Self (DS; acting in ways inconsistent with inner thoughts and feelings), an STSS subscale, was targeted for study along with the total STSS score. Participants were 513 women from the U.S. Women's Interagency HIV Study (M age = 46; 387, 75%, Black; 66, 13%, Hispanic; 60, 12%, White). Multiple logistic regressions indicated that across all racial/ethnic groups, physical abuse history related to higher DS and lower adherence. DS significantly mediated relationships between abuse and adherence. Compared to White women, Black women demonstrated worse ART adherence, but had lower total STSS. Racial/ethnic minority women and women with a physical abuse history who had higher DS had lower adherence than other groups. Results indicate that being a racial/ethnic minority or having a history of physical abuse may increase vulnerability to the deleterious effects of DS on ART adherence, findings that can help inform interventions to decrease health disparities in WLWH.

Mindfulness and experiential avoidance as predictors and outcomes of the narrative emotional disclosure task.

This randomized study examined whether narrative emotional disclosure improves mindfulness, experiential avoidance, and mental health, and how baseline levels of and changes in mindfulness and experiential avoidance relate to mental health. Participants (N=233) wrote repeated traumatic (experimental condition) or unemotional daily events narratives (control condition). Regression analyses showed neither condition nor gender effects on mental health or experiential avoidance at a 1-month follow-up, although the control condition significantly increased in one component of mindfulness. Decreased experiential avoidance (across conditions) and increased mindfulness (in the experimental condition) significantly predicted improved mental health. Narrative disclosure thus did not improve outcomes measured here. However, increasing mindfulness when writing narratives with traumatic content, and decreasing experiential avoidance regardless of writing content, was associated with improved mental health.

Linguistic Predictors of Mindfulness in Written Self-Disclosure Narratives.

This study investigated whether relative changes in cognitive, emotion, temporal, and self-reference word frequencies in repeated narratives predicted improvements in mindfulness skills (i.e., nonjudgmental acceptance of present-moment experiences, observing and describing present stimuli, and acting with awareness) subsequent to narrative self-disclosure. Participants wrote repeated narratives of traumatic or daily events over 3 days. Mindfulness was assessed at baseline and 4 to 8 weeks posttask. Results indicated that relative increases in cognitive processing words (among traumatic events participants and women in both conditions) and present tense words (among all participants) significantly predicted increases in nonjudgmental acceptance, describing, or overall mindfulness. Increases in present tense words appeared to partially mediate the higher mindfulness outcomes of participants writing about daily events when compared with those writing about trauma. The findings suggest that linguistic changes in self-disclosure narratives are associated with improvements in specific mindfulness skills.

Self-Silencing, but Not Sexual Relationship Power Associated with Condom Use for Black College-Aged Women.

Black adolescent and young adult women in the United States experience a disproportionately higher rate of HIV infections than White and Hispanic adolescent and young adult women. Heterosexual sexual activity is the main route of infection for women, regardless of race or ethnicity. We examined two potential barriers to reducing Black adolescent and young adult women's HIV risk: high levels of self-silencing and low levels of sexual relationship power. Data were collected on a small convenience sample of sexually active Black college-aged women (N = 57, Mage = 19.6, SD = 1.4) who answered questions about their current or most recent dating relationship. We found that higher levels of self-silencing were significantly related to lower condom use frequency and to a lower likelihood of reporting condom use at last sex. No significant associations were found between sexual relationship power and condom use (frequency or at last sex). Data from this study suggest that self-silencing, which involves putting the needs of others ahead of one's own in order to avoid conflict in relationships, is an important variable to consider when examining potential risk factors for sexually transmitted HIV among Black college-aged women. Implications for future studies on HIV risk are reviewed.

Life Lessons from Women with HIV: Mutuality, Self-Awareness, and Self-Efficacy.

Women with HIV in the United States cope with multiple traumas that influence adherence to antiretroviral therapy (ART) and well-being. Narrative themes from three life turning points and a projective story task were compared for two groups of women with HIV (HIV well-managed vs. HIV not well-managed, matched on demographics and narrative word count) to understand predictors of successful outcomes. The well-managed group (n = 10) was virally suppressed and reported ≥95% ART adherence; the not well-managed group (n = 10) had detectable viral load and reported <95% ART adherence. Women were predominantly African American with low socioeconomic status and averaged 46.51 years. A three-stage coding process (with coders blind to group status in stages 1 and 2) involved (1) line by line thematic analyses that generated 155 subthemes reflecting six content areas (interpersonal relationships; culture and community; sense of self; relationship to past, present, and future experiences; self-care; and motivators for change); (2) absence/presence of the 155 subthemes was compared for the two groups; the frequency of 37 subthemes was found to significantly differ; and (3) the 37 differentiating subthemes were conceptually integrated, revealing that the well-managed group's narratives more frequently reflected (a) mutuality (growth-fostering relationships involving reciprocal care and empathy); (b) self-awareness (recognition of personal strengths and weaknesses and multiple factors contributing to life choices and trajectories); and (c) self-efficacy (active coping, self-advocacy, and utilizing resources). Implications for treatment and interconnections among themes are discussed, emphasizing the factors that enable women to care for themselves and others.

Gender Roles and Mental Health in Women With and at Risk for HIV.

Predominantly low-income and African American women from the same community, HIV-infected (n = 100; HIV+) and uninfected (n = 42; HIV-), were assessed on reported gender roles in sexual and other close relationships-including levels of self-silencing, unmitigated communion, and sexual relationship power-at a single recent study visit during 2008-2012. Recent gender roles were investigated in relation to depressive symptoms and health-related quality of life assessed both at a single visit during 2008-2012 and averaged over semiannual visits (for depressive symptoms) and annual visits (for quality of life) occurring between 1994 and 2012. Compared to HIV- women, HIV+ women reported significantly higher levels of several aspects of self-silencing, unmitigated communion, and multi-year averaged depressive symptoms as well as lower levels of sexual relationship power and recent and multi-year averaged quality of life. For both HIV+ and HIV- women, higher self-silencing and unmitigated communion significantly related to recent or multi-year averaged higher depressive symptoms and lower quality of life. Intervention strategies designed to increase self-care and self-advocacy in the context of relationships could potentially minimize depressive symptoms and enhance quality of life in women with and at risk for HIV.

Resilience among women with HIV: Impact of silencing the self and socioeconomic factors.

In the U.S., women account for over a quarter of the approximately 50,000 annual new HIV diagnoses and face intersecting and ubiquitous adversities including gender inequities, sexism, poverty, violence, and limited access to quality education and employment. Women are also subjected to prescribed gender roles such as silencing their needs in interpersonal relationships, which may lessen their ability to be resilient and function adaptively following adversity. Previous studies have often highlighted the struggles encountered by women with HIV without focusing on their strengths. The present cross-sectional study investigated the relationships of silencing the self and socioeconomic factors (education, employment, and income) with resilience in a sample of women with HIV. The sample consisted of 85 women with HIV, diverse ethnic/racial groups, aged 24 - 65 enrolled at the Chicago site of the Women's Interagency HIV Study in the midwestern region of the United States. Measures included the Connor-Davidson Resilience Scale -10 item and the Silencing the Self Scale (STSS). Participants showed high levels of resilience. Women with lower scores on the STSS (lower self-silencing) reported significantly higher resilience compared to women with higher STSS scores. Although employment significantly related to higher resilience, silencing the self tended to predict resilience over and above the contributions of employment, income, and education. Results suggest that intervention and prevention efforts aimed at decreasing silencing the self and increasing employment opportunities may improve resilience.

Are there specific metacognitive processes associated with anxiety disorders in youth?

While Wells' metacognitive model of generalized anxiety disorder (GAD) posits that certain metacognitive processes, such as negative meta-worry (negative beliefs about worry), are more strongly associated with symptoms of GAD than other anxiety disorders in adults, research has yet to determine whether the same pattern is true for younger individuals. We examined the relationship between several metacognitive processes and anxiety disorder diagnostic status in a sample of 98 youth aged 7-17 years. Twenty youth with GAD were compared with similarly sized groups of youth with obsessive-compulsive disorder (OCD, n = 18), social phobia (SOC, n = 20), separation anxiety disorder (SAD, n = 20), and healthy controls who were not patients (NONP, n = 20) using a self-report measure of metacognition adapted for use with young people in this age range (Metacognitions Questionnaire for Children). Contrary to expectations, only one specific metacognitive process was significantly associated with an anxiety disorder diagnosis, in that the controls endorsed a greater degree of cognitive monitoring (self-reported awareness of one's thoughts) than those with SAD. In addition, there was a trend indicating that nonpatients scored higher than youth with GAD on this scale. These surprising results suggest potentially differing patterns in the relationships between symptoms and metacognitive awareness in anxious youth, depending on the type of anxiety disorder presentation.

The metacognitions questionnaire for children: development and validation in a clinical sample of children and adolescents with anxiety disorders.

A self-report measure of metacognition for both children and adolescents (ages 7-17) (Metacognitions Questionnaire for Children; MCQ-C) was adapted from a previous measure, the MCQ-A (Metacognitions Questionnaire for Adolescents) and was administered to a sample of 78 children and adolescents with clinical anxiety disorders and 20 non-clinical youth. The metacognitive processes included were (1) positive beliefs about worry (positive meta-worry); (2) negative beliefs about worry (negative meta-worry); (3) superstitious, punishment and responsibility beliefs (SPR beliefs) and (4) cognitive monitoring (awareness of one's own thoughts). The MCQ-C demonstrated good internal-consistency reliability, as well as concurrent and criterion validity, and four valid factors. In line with predictions, negative meta-worry was significantly associated with self-reports of internalizing symptoms (excessive worry and depression). Age-based differences on the MCQ-C were found for only one subscale, with adolescents reporting greater awareness of their thoughts than children. Adolescent girls scored higher on the total index of metacognitive processes than adolescent boys. Overall, these results provide preliminary support for the use of the MCQ-C with a broader age range as well as an association between metacognitive processes and anxiety symptomatology in both children and adolescents, with implications for cognitive behavioral interventions with anxious youth.