Coping and adjustment to genital herpes: the effects of time and social support

Impact of primary and recurrent genital herpes on the quality of life of young people and adults: a mixed methods systematic review

OBJECTIVE

This review sought to identify the experiences of persons living with genital herpes and what interventions improve the health-related quality of life of young people and adults with primary or recurrent genital herpes.

INTRODUCTION

Genital herpes is commonly associated with psychosocial challenges. However, a growing body of evidence suggests that its impact can be ameliorated through pharmacological and psychosocial interventions.

INCLUSION CRITERIA

This review considered English- and German-language studies of community-dwelling males and females, of any ethnicity and geographical location, aged 15 years and older, who had primary or recurrent genital herpes. The quantitative component of the review included studies that reported on the virus' impact on patients' health-related quality of life and/or the efficacy of interventions in improving their health-related quality of life. Studies compared antiviral suppression therapies and psychological interventions with usual care or placebo, or against one another. The qualitative component of the review included studies that investigated the perceptions and experiences of young people and adults with genital herpes.

METHODS

Eleven databases were searched from January 1980 to March 2020. The JBI approach to mixed methods systematic reviews was followed at each stage of the review, and a convergent segregated approach to synthesis and integration was adopted.

RESULTS

A total of 31 publications covering 30 studies were deemed suitable for inclusion. Studies encompassed quantitative (n = 27, across 28 publications), qualitative (n = 1), and mixed methods (n = 2) designs. Critical appraisal scores were variable, particularly among the randomized controlled trials and the analytical cross-sectional studies. All studies were included regardless of methodological quality. The quantitative components identified that depression, illness concern, stress, anxiety, isolation, stigma, and a lowering of self-esteem, self-concept, self-confidence, and health-related quality of life may be experienced by both those newly diagnosed with genital herpes and those with recurrences. It was also identified that genital herpes can have an adverse effect on work or school, sexual relationships, and relationships with friends and family. Depression was found to significantly decrease after self-hypnosis and certain psychosocial interventions. Anxiety significantly decreased following pharmacological treatment, psychosocial interventions, and hypnosis. Psychosocial interventions significantly improved mood, and a self-help module with counseling significantly improved participants' satisfaction with intimate relationships and their self-esteem. Pharmacological treatment significantly improved health-related quality of life; however, there were no significant differences between different active treatment regimens. The qualitative component of the review led to the identification of two synthesized findings: "Disclosure of a diagnosis of genital herpes poses a dilemma for people who have the virus" and "A diagnosis of genital herpes has a significant emotional impact for the individual."Integration of quantitative and qualitative evidence revealed a consensus that a diagnosis of genital herpes has a significant emotional impact for individuals and that disclosure is stressful, affects relationships, and affects health-related quality of life; however, there is a lack of consensus regarding efficacy of different interventions.

CONCLUSIONS

Genital herpes can lead to extreme emotional, social, relational, and sexual distress, but there is insufficient knowledge concerning which interventions best improve health-related quality of life. More high-quality research is required.

Psychological symptoms associated with genital herpes virus infections: epidemiology and approaches to management

Genital herpes is a common, chronic, recurrent, viral sexually transmitted infection (STI) occurring worldwide. The first episode may be severe and prolonged, but most recurrences are usually short lived and minor. Although most individuals with this infection have no symptoms, STIs, including genital herpes, often cause psychological and psychosexual morbidity. Unfortunately, the existing data on the psychological symptoms associated with genital herpes have many limitations, including anecdotal reporting, evaluation of small and selected populations, use of varied and sometimes unevaluated questionnaires, and lack of controls. Some individuals with recurrent genital herpes display a range of emotional responses, including depression, anguish, distress, anger, diminution of self-esteem and hostility towards the person believed to be the source of infection. However, it is always important to consider the possibility of pre-existing psychopathology. Several retrospective studies have suggested that stress could lead to recurrences of genital herpes infection. However, prospective studies have been unable to demonstrate any relationship between pre-existing stress and recurrences. What these studies were able to demonstrate was that stress and recurrences occurred simultaneously, suggesting that perhaps it was the recurrences that were causing stress, rather than the reverse.

Public tolerance, private pain: stigma and sexually transmitted infections in the American Deep South

This pilot telephone survey sought to identify social barriers to treating sexually transmitted infections (STIs) in a socially conservative state (Alabama, USA). The sample consisted of 250 household residents aged 19-50 years, mostly African-American and White, who were drawn from the general population. The participants reported that infected persons, per se, should not be stigmatized. However, almost half of respondents stated that they would seek revenge against a partner who infected them. Feelings of embarrassment negatively affected willingness to seek health care; almost half of the respondents stated that, if infected, they would delay treatment or not seek treatment at all. Differences in responses emerged in relation to ethnicity and religiosity, with African-Americans and regular churchgoers being more likely than others to say they would delay or refuse treatment because of embarrassment. Gender differences also emerged: respondents reported that women would be more stigmatized than men if they were infected, even though men should be held responsible for spreading STIs. These findings suggest that stigma may be a compelling barrier to STI control in the American Deep South, and that ethnicity, gender and religiosity play an important role in attitudes toward treatment.

Psychosocial impact of serological diagnosis of herpes simplex virus type 2: a qualitative assessment

OBJECTIVES

To assess the emotional and psychosocial responses to a serological diagnosis of HSV-2 infection in individuals without previous history of genital herpes.

METHODS

24 individuals who had a positive HSV-2 serology by western blot and no clinical history of disease were recruited from four clinics (sexually transmitted disease, maternal and infant care, family medicine, and virology research) over a 10 month period. In-depth qualitative interviews were conducted to elicit an individual's responses to the HSV-2 diagnosis.

RESULTS

Three categories of themes were identified from the interviews. Short term emotional responses included surprise, denial, confusion, distress, sadness, disappointment, and relief to know. Short term psychosocial responses included fear of telling sex partners, anger at the source partner, guilt about acquiring or transmitting, and concern about transmitting to a child. Perceived ongoing responses included fear of telling future partners, concern about transmitting to a sex partner, feeling sexually undesirable, feeling socially stigmatised, feeling like "damaged goods," sex avoidance due to social responsibility, fear of transmitting to a newborn, and relationship concerns relating to the diagnosis.

CONCLUSIONS

Individuals exhibit strong emotional and psychosocial responses to a serological diagnosis of HSV-2 infection. Many of the negative responses may be time limited and influenced by factors that are potentially amenable to counselling.

Quality and ecology of adversity as common mechanisms of risk and resilience

This paper proposes common mechanisms to explain the effects of adversities and of resources that promote resilience. Adversities threaten the satisfaction of basic human needs and the acquisitions of competencies to carry out valued social roles. Adversities can also be characterized in terms of their ecological properties of occurrence in time, and place. Resilience resources at the individual, microsystem and macro levels reduce the negative effects of adversities through their effects on satisfaction of basic human needs and their effects on the occurrence of adversities. The effects of resilience resources are described as preventive, protective and promotive. Implications are presented for the development of interventions to promote resilience.

Gender differences for the predictors of depression in young adults with genital herpes

Genital herpes is a chronic, stigmatizing, sexually transmitted disease (STD), which is increasing despite efforts to control its spread. Depression is commonly reported among people diagnosed with genital herpes and differences in depression by gender have been reported. Therefore, the purpose of this study was to identify gender differences in the predictors of depression in young adults with genital herpes by secondary analyses of baseline data from a randomized clinical trial (RCT). For the RCT, young adults (193 females, 59 males) with genital herpes were recruited from newspaper advertisements. Participants completed questionnaires measuring illness burden, attitudes toward herpes, stress symptoms, mood states, depression, self-concealment, self-disclosure, substance use, and demographics. Univariate analyses and multiple regression techniques were used to identify variables predictive of depression in this sample. In women, increased anger, decreased vigor, increased confusion, a negative attitude toward herpes, self-concealment, and stress symptoms from genital herpes predicted more depression (R2 = 0.63). In men, increased depression was predicted by increased anger, a negative attitude toward herpes, and a decreased willingness to share personal information with a stranger (R2 = 0.51). Findings suggest that future psychoeducational interventions should address anger as a predictor of depression in this population. Gender-specific interventions need to be developed in order to assist young adults who are living with genital herpes.

Effects of psycho-educational interventions on sexual health risks and psycho-social adaptation in young adults with genital herpes

The purpose of this study was to test the outcomes of group psycho-educational intervention (PEI) led by nurses on sexual health risks (knowledge, behaviour, disease burden) and psycho-social adaptation (depression, mood states, self-efficacy) in young adults with the chronic disease, genital herpes. Two hundred and fifty-two young adults with symptomatic genital herpes participated in a randomized controlled trial (RCT). The intervention was participation in a three-session group PEI facilitated by a nurse in the community. Participants completed questionnaires measuring sexual health risks (herpes knowledge, sexual risk behaviour, disease burden of patterns of recurrences of outbreaks of the disease), and psycho-social adaptation (depression using the Beck Depression Inventory [BDI], mood states using the Profile of Mood States [POMS], and feelings of self-efficacy for protection from sexually transmitted diseases [PSTD]) at induction into the study, and at 3 and 6 months. Participants were mainly employed, Caucasian, single women in their twenties (X = 27.1 years, SD = 4.3), with some college education; 23% of the sample were men. After controlling for baseline knowledge about genital herpes, the experimental group had significantly more knowledge than the control group at 3 and 6 months' post-intervention. They also reported using condoms and spermicides to prevent the spread of genital herpes more often than did the control group. The implications for nurses in the community include the following: (a) PEI is an intervention that can be used by nurses in the community with a high-risk population; (b) group intervention is a viable treatment for people with a highly stigmatized, chronic sexually transmitted disease (STD); and (c) further testing of the use of PEI by nurses in the community with other high-risk populations is needed.

Psychological factors in recurrent genital herpes

OBJECTIVES

To review recent research into psychological aspects of genital herpes and assess possible implications for clinical practice.

METHODS

Review of all papers in the field on Medline 1985-96.

RESULTS

Much attention has been paid to possible links between stress and recurrent genital herpes. There is no convincing evidence that stress in itself causes recurrences. It may be that recurrences are preceded by a prodromal period of altered mood. Patients with recurrences show considerable stress as a result of the disease, although most individuals eventually adjust psychologically. The impact of social support on adjustment remains unclear. The little evidence available suggests that antiviral treatments can help adjustment and the effects may perhaps outlast the period of active treatment.

CONCLUSIONS

Existing research gives some clues to optimal patient management but there is a need for future research to focus much more clearly on clinical issues, particularly on means of alleviating psychological distress and on the impact of antivirals.

Genital herpes: an integrated approach to management

This review of epidemiologic, clinical, and psychosocial/psychobehavioral data related to genital herpes simplex virus infection details the increasing incidence of herpes simplex virus infection in the United States and summarizes the data regarding the safety and efficacy of chronic and acute antiviral therapy with acyclovir. It additionally establishes the validity of psychosocial intervention as an adjunct to pharmacologic therapy for patients with recurrent genital herpes.

Measuring health-related quality of life in persons with genital herpes

A disease-specific measure was needed for use in an international clinical trial to evaluate an investigational drug for genital herpes. A new measure was developed initially in the UK and translated and adapted for use in France, Italy, Germany, Denmark, Spain and the USA. This paper describes the translation and adaptation of the USA measure. It also describes the assessment of internal consistency, reproducibility, content validity, and construct validity (convergent and discriminant) of the measure. Two outcome measures of the final genital herpes-specific measure were developed: (1) a 21-item symptoms subscale; and (2) a 20-item HRQOL subscale. Each measure was scored and analyzed separately; the psychometric testing discussed in this paper refers to the HRQOL subscale only. The internal consistency of the HRQOL subscale is high (r = 0.93), as is the reproducibility measured with a two week interval (r = 0.85). Convergent validity is moderate to high. (Fleming Self-Regard subscale, r = 0.48; SF-36 Social Functioning dimension r = 0.59; SF-36 Mental Health dimension r = 0.50). The number of herpes outbreaks in the past year was a significant predictor of scores on the HRQOL subscale (0-1 outbreaks, mean = 82.1; 2+ outbreaks, mean = 72.1, p = 0.058) suggesting discriminant validity. The measure is currently in a phase III clinical trial including anti-viral therapy where the question of responsiveness can be addressed.

Clinical features and psychosocial factors in young adults with genital herpes

Clinical features of genital herpes, perceived causes, stress symptoms, treatments, and psychosocial factors in 70 young adults as compared to normative data for non-patient controls are described. The clinical features of the disease were congruent with those of other groups studied. Stress was viewed as the major cause of recurrence, headaches the major stress symptom, and acyclovir (an antiviral drug), was the major treatment. Statistically significant differences were found between scores obtained from the sample of young adults with genital herpes on three of four standardized psychological instruments when compared with normative data for non patient controls. Young adults with genital herpes had a lower self concept, more psychopathology, a greater frequency of daily hassles, and less intensity of uplifts. No differences were found, however, between the two groups in scores on depression.

Psychosocial factors and recurrent genital herpes: a review of prediction and psychiatric treatment studies

OBJECTIVE

The purpose of this review was to evaluate the evidence which supports the association between psychosocial factors and genital herpes simplex virus recurrences (HSV), as well as to examine the biological and psychological treatments for disease.

METHOD

Forty-five studies were reviewed from the years 1928 to 1991. Studies were identified via computerized biographic literature search of Psychological Abstracts and Medline. Additional studies were located by inspection of key article reference sections. Studies were included in the review if the sample consisted of recurrent genital herpes sufferers and the design was either correlational or experimental. Cases studies were reviewed if they described HSV psychiatric treatment and provided outcome information.

RESULTS

Psychosocial variables are important elements in the prediction, maintenance, and management of recurrent genital herpes. Furthermore, the effectiveness of psychological treatment regimes may be explained via psychoimmunological theory.

CONCLUSIONS

Psychosocial treatment should be considered as adjunctive therapy for biological treatment of recurrent HSV infections. Future research should address primary prevention of genital herpes and other sexually transmitted diseases, including HIV infections.

Perceived stressors and coping responses in persons with recurrent genital herpes

This descriptive study was designed to examine the disease experience of persons who have genital herpes by identifying the nature and frequency of disease-related stressors and coping responses associated with these stressors. Participants were 34 women and 26 men who were on average 5.3 years postdiagnosis, and experienced a mean of 6.4 recurrences per year. Respondents reported a wide range of disease-related stressors (M = 7). The category of stressors identified most often was related to disease consequences (73.9%), and included difficulty with intimate relationships, difficulty with relationships involving family and friends, fear of transmission through both sexual activity and casual contact, and concern about negative effect on health. Respondents tended to use active coping, planning, and acceptance more often than passive strategies such as denial. Implications for clinical assessment and intervention are discussed.

Psychosocial factors affecting genital herpes recurrences: linear vs mediating models

Psychosocial factors (emotional distress, stress, health locus of control, and social support) and genital herpes activity (episode frequency, severity, and duration) were assessed for 46 individuals with recurrent genital herpes infections (HSV) in order to predict psychosocial status associated with herpes episodes. Multiple regression analyses revealed that stress and emotional distress accounted for 52% of HSV episode frequency variance, whereas 49% of the episode severity variance was determined by emotional distress and health locus of control. The buffering effects of time and health locus of control were functional only for herpes frequency. Linear predictive models appear to offer a better opportunity for understanding how psychosocial factors affect genital herpes outbreaks than do interactive or buffering models. Results were discussed in terms of the biopsychosocial model of health.