Full text of DOI:10.1207/S15327558IJBM0702_5

INTERNATIONAL JOURNAL OF BEHAVIORAL MEDICINE, 7(2), 160–182
Copyright © 2000, Lawrence Erlbaum Associates, Inc.
Optimism, Distress, and Immunologic
Status in HIV-Infected Gay Men
Following Hurricane Andrew
Stacy Cruess, Michael Antoni, Kristin Kilbourn,
Gail Ironson, Nancy Klimas, and Mary Ann Fletcher,
Andy Baum, and Neil Schneiderman
This study investigated how dispositional optimism relates to psychological and im-
munologic status in 40 HIV-infected gay men residing in areas of South Florida hard
hit by Hurricane Andrew. In the months following the storm, participants’ levels of
psychological distress (hurricane-related and overall distress) and antibody titers to
several herpesviruses (Herpes Simplex Virus–2, Epstein–Barr Virus [EBV],
Cytomegalovirus, and Human Herpes Virus–6 [HHV–6]) were measured. Overall,
participants had elevated mean levels of hurricane-specific and general distress.
Higher levels of optimism were related to lower levels of depression, overall distress,
and hurricane-specific posttraumatic stress disorder symptoms. After controlling for
nonspecific polyclonal B cell activation, greater optimism was also associated with
lower levels of circulating antibodies to EBV and HHV–6, suggesting better cellular
immunologic control over these viruses among optimists. Regression analyses
showedthattherelationbetweenoptimismandlowerEBVtiterswaspartiallymediated
by the lower depression levels experienced by optimists.
Key
words:
HIV,
hurricane,
immunity,
natural
disasters,
optimism,
psychoneuroimmunology
HIV infection is often associated with chronic psychological, behavioral, and phys-
ical burdens. The ongoing stress of the social stigma associated with HIV and rigor-
ous treatment regimens may also be compounded by acute stressors, such as multi-
ple bereavements, onset of HIV-related symptoms, or other non-HIV-related
Stacy Cruess, Michael Antoni, Kristin Kilbourn, Gail Ironson, Nancy Klimas, and Mary Ann
Fletcher, University of Miami, Coral Gables, FL, USA; Andy Baum, University of Pittsburgh, Pitts-
burgh, PA, USA; Neil Schneiderman, University of Miami, Coral Gables, FL, USA.
Correspondence concerning this article should be addressed to Michael H. Antoni, Department of
Psychology, P.O. Box 248185, University of Miami, Coral Gables, FL 33124.

OPTIMISM AND HIV AFTER HURRICANE ANDREW
161
events. Although numerous studies have examined the psychological and physio-
logical concomitants of the stress of HIV infection, few have looked at the added
impact of additional acute stressors. The occurrence of Hurricane Andrew on Au-
gust 24, 1992 provided the unique opportunity to examine this phenomenon on the
psychological and immunological status of a group of HIV-infected men who were
suddenly faced with the added stress of a severe environmental event.
Researchers have studied the impact of a wide range of catastrophic events such
as the Three Mile Island (TMI) nuclear reactor accident (Baum, Gatchel, &
Schaffer, 1983), the Buffalo Creek flood (Lifton & Olsen, 1976) , the Loma Prieta
Earthquake (Nolen-Hoeksema & Morrow, 1991), and more recently the
Northridge Earthquake (Solomon, Segerstrom, Grohr, Kemeny, & Fahey, 1997)
and Hurricane Andrew (Benight et al., 1997; Ironson et al., 1997; Lutgendorf et al.,
1
995). Many studies examining the psychological sequelae of natural disasters
have found substantial levels of anxiety, depression and symptoms of
posttraumatic stress disorder (PTSD) in the months after their occurrence (Baum
et al., 1983; Ironson et al., 1997; McFarlane & Papay, 1992; Nolen-Hoeksema &
Morrow, 1991). These negative psychological consequences are often not
short-lived (Davidson & Baum, 1986; Ironson et al., 1997). In addition to these
deleterious psychological sequelae of natural disasters, there is a growing body of
literature suggesting possible detrimental physical effects in previously healthy in-
dividuals (Clayer, Bookless-Pratz,
Rubio-Stepec, & Bravo, 1992; Janerich et al., 1981; Logue, Hansen, & Streuning,
979; Phifer, Kaniasty, & Norris, 1988). The TMI accident was associated with
& Harris, 1985; Escobar, Canino,
1
neuroendocrine and immunologic changes in residents of the surrounding commu-
nity, suggesting possible pathways through which health changes may occur
(Baum et al., 1983; Collins, Baum, & Singer, 1983; Davidson, Fleming, & Baum,
1
1
987; McKinnon, Wiesse, Reynolds, Bowles, & Baum, 1989; Solomon et al.,
997). Numerous other studies examining the immunologic consequences of more
commonplace stressors (Glaser, Kiecolt-Glaser, Speicher, & Holliday, 1985;
Glaser et al., 1991; Kiecolt-Glaser et al., 1987; Kiecolt-Glaser et al., 1987;
Kiecolt-Glaser et al., 1985;) and natural disasters (Solomon et al., 1997) suggest
that exposure to a major uncontrollable stressor, such as a natural disaster, may be
associated with changes in immune functioning and subsequent health changes.
Although the sequelae of environmental disasters have been fairly well docu-
mented in healthy populations, far fewer studies have examined their effects on in-
dividuals with a preexisting physical illness. One study of rheumatoid arthritis
(RA) patients found increases in arthritic flares and progression into more ad-
vanced disease state in patients exposed to either Hurricane Hugo or the San Fran-
cisco earthquake (Grady et al., 1991). Another study documented exacerbations in
physical symptoms and clinical relapses among Chronic Fatigue Syndrome (CFS)
patients residing in high-impact areas of Hurricane Andrew as compared to pa-
tients in low impact areas (Lutgendorf et al., 1995).

162
CRUESS ET AL.
Recent work has documented physiological and psychological changes in
HIV+ people following Hurricane Andrew and that individual difference factors
may act to buffer some of these changes. Benight et al. (1997) found that a greater
sense of coping self-efficacy was associated with lower levels of psychological
distress and symptoms of PTSD in a sample of HIV-infected gay men following
Hurricane Andrew. In addition, less coping self-efficacy was associated with
higher urinary 24-hr norepinephrine-to-cortisol ratios, suggesting that poorer re-
covery of hormonal regulation was associated with less self-efficacy (Benight et
al., 1997). These findings suggest that HIV-infected men with low perceived cop-
ing resources may be at risk for neuroendocrine disruptions in the face of uncon-
trollable stress, which could possibly be related to disruptions in immune
functioning (Irwin, Daniels, Smith, Bloom, & Weiner, 1987a; Irwin, Daniels,
Smith, Bloom, & Weiner, 1987b).
Because HIV-infected individuals are immunocompromised, they may have
less protection against preexisting pathogens (e.g., latent viruses and new infec-
tious agents) associated with the development of both disease and non-disease-
related physical symptoms than healthy individuals; even small stress-associated
immune changes (presumably due to neuroendocrine disruption) may have health
implications (Antoni, Esterling, Lutgendorf, Fletcher, & Schneiderman, 1995).
Dysregulation of the immune system’s ability to control latent viruses may be of
particular importance for HIV-infected individuals because there is growing sup-
port for the possible role of several herpesviruses—common viruses that often re-
main latent in the body—as “cofactors” that may influence the course of disease
progression (Kucera, Leake, Iyer, Raben, & Myrvik, 1990; Lusso et al., 1990).
Kucera et al. (1990) found that HIV and Herpes Simplex Virus–Type 2 (HSV–2)
can not only coinfect the same cell and simultaneously replicate, but that
coinfection of HIV and HSV–2 may result in accelerated replication of HIV. Simi-
larly Lusso et al. (1990) found an acceleration of HIV-related antigen expression
in cells coinfected with HIV and human herpes virus–6 (HHV–6) and concluded
that HHV–6 may be an important cofactor in the development of acquired immune
deficiency syndrome (AIDS). Numerous studies have also found that HIV+ indi-
viduals have a higher level of circulating Epstein–Barr Virus (EBV) antibody
titers than do HIV– individuals, suggesting poorer cellular control over this herpes
virus (Esterling et al., 1992; Giraldo, Beth-Giraldo, Serwadda,
Katongole-Mbidde, & Gallo, 1990). Birx, Redfield, and Tosato (1986) also found
that patients with AIDS-related Complex and AIDS patients evidence defective
regulation of EBV-infected B lymphocytes and an abnormally high number of cir-
culating EBV-infected cells. Furthermore, one prospective study found that not
only do HIV+ individuals have high levels of EBV antibody titers, but that EBV
titers seem to increase immediately following HIV seroconversion and prior to
disease progression (Margalith et al., 1990). There appears to be sufficient evi-
dence for the hypothesis that reactivated latent herpesvirus infections may play a

OPTIMISM AND HIV AFTER HURRICANE ANDREW
163
contributing role in the progression of HIV-related immune decrements and subse-
quent disease progression (Antoni et al., 1995).
Importantly, psychological factors such as distress and depression and certain
personality factors appear to be related to control over these latent viruses in other
populations (Esterling, Antoni, Fletcher, Margulies, & Schneiderman, 1994;
Esterling, Antoni, Kumar, & Schneiderman, 1990). Some work suggests that one
personality characteristic—optimism—may work to offset the effects of natural
disasters in medical populations (Lutgendorf et al., 1995). We reasoned that opti-
mism may relate to better health status in the face of severe stressors among
HIV-infected persons through its effects on immune system status. Here optimism
may relate to immunologic status in HIV+ persons through its ability to minimize
distress levels in the wake of stressful challenges. Although several recent studies
have examined the relation of optimism and immune functioning in healthy popu-
lations (Cohen et al., 1999; Segerstrom, Taylor, Kemeny, & Fahey, 1998), no
work to date has evaluated associations between optimism and immune status and
the role of distress or depression as a mediator in HIV+ persons dealing with recent
stressors.
We had the opportunity to study these processes in a cohort of HIV-infected
gay men who were dealing with the concurrent stressors of their disease and a ma-
jor natural disaster—Hurricane Andrew. Hurricane Andrew hit southern Florida
on August 24, 1992 and was one of the most devastating hurricanes to ever hit the
United States. The terrifying few hours that it took Hurricane Andrew to take its
toll on Dade County resulted in damage and destruction that has taken years to re-
cover from. Estimated property damages were in excess of 30 billion dollars; en-
tire neighborhoods were destroyed, leaving nearly 200,000 families homeless.
Millions of others were without electricity and phones for weeks. The physical
damage was compounded by the emotional impact of the storm. During the storm,
many individuals reported feeling as if there lives were in danger (Ironson et al.,
1
997; Lutgendorf et al., 1995). Afterwards, residents had to cope with the wide-
spread loss and the subsequent hassles involved in rebuilding, as well as the emo-
tional impact, for many months following the storm (Burnett et al., 1997). This
study examines how dispositional optimism relates to the psychological and im-
munologic sequelae of Hurricane Andrew in a group of primarily asymptomatic
and early symptomatic HIV-infected gay men residing in areas of South Florida
hardest hit by the storm. Specifically, we hypothesized that (a) men with the great-
est posthurricane distress levels would show the highest IgG antibody titers (re-
flecting poorer immunologic control) to four common herpesviruses; (b) more
optimistic men would reveal both lower levels of distress, depression, and PTSD
symptoms, and better immunologic control of latent herpesviruses; and (c) the as-
sociation between optimism and immune function would be mediated by these
psychological states.

164
CRUESS ET AL.
METHOD
Participants
Forty-four HIV-infected gay or bisexual men agreed to participate in a study in-
vestigating psychological and physiological sequelae of Hurricane Andrew. Par-
ticipants were recruited through flyers, HIV/AIDS service organizations, and
special immunology clinics at two major hospitals in the Southeast. Only those
individuals residing in Dade County at the time of Hurricane Andrew and at the
time of entry into the study (within the 6 months immediately following the
storm) were included as participants. Two men were excluded from the study
because they were not in Dade County during the landfall of the hurricane. All
but one of the participants were asymptomatic or mildly symptomatic at the time
of the first assessments. Two participants were dropped from the study because
they did not complete the assessments, leaving a total of 40 participants who
completed the study.
Psychological Measures
PTSD scale. The PTSD scale used in this study consists of the Diagnostic
and Statistical Manual of Mental Disorders (3rd ed., rev. [DSM–III–R]; American
Psychological Association, 1994) criteria for PTSD put into questionnaire form.
Respondents were asked to indicate how frequently they had each of the symptoms
in relation to the hurricane during the past week. Responses are rated on a 5-point
Likert scale ranging from 0 (not at all) to 4 (every day). Item examples include,
“
How frequently have you been jumpy or easily startled?,” “How frequently have
you been upset by something that reminded you of the event?,” and “ How fre-
quently have you been avoiding any thoughts or feelings about the event?” The
scale yields three subscores commensurate with DSM–III–R PTSD symptom cate-
gories (Avoidance, Intrusion, and Hyperarousal), as well as a total PTSD score that
is obtained by summing the three subscores.
Symptom Checklist–90–Revised (SCL–90–R). The SCL–90–R (Derogatis,
1
983) was administered to all participants as a measure of general psychological
distress. The SCL–90–R is a 90-item self-report measure designed to assess pat-
terns of symptoms in psychiatric, medical, and community samples. Each of the 90
items is rated on a 4-point scale ranging from 1 (not at all) to 4 (extremely). The
scales of interest in this study were the depression subscale and a global index of
distress, the Global Severity Index (GSI). The SCL–90–R has been shown to have
high internal consistency and test–retest reliability and adequate validity
(Derogatis, 1983).

OPTIMISM AND HIV AFTER HURRICANE ANDREW
165
Impact of Events Scale (IES). To more specifically address the cognitive
aspects of distress related to hurricane experiences, we administered the IES
(Horowitz, Wilner, & Alverez, 1979), a 15 item self-report measure designed to as-
sess subjective distress as a result of a particular life event. Responses are rated on a
scale ranging from 1 (not at all) to 4 (often) and then transformed to a 0, 1, 3, 5 scale.
The IES contains two subscales, both empirically supported by factor analysis. The
first, an intrusion subscale, measures the extent to which an individual experiences
unwanted thoughts and images that are related to a particular life stressor. Exam-
ples include, “I had trouble falling asleep or staying asleep because of pictures or
thoughts about it that came into my mind.” The second subscale, avoidance, as-
sesses the degree to which an individual must consciously take action to distract
himself or herself in order to avoid thinking about a situation. The IES has shown
good test–retest reliability (Horowitz, Wilner, & Alverez, 1979) and cross-valida-
tion (Zilberg, Weiss, & Horowitz, 1982). In this study, two separate versions of the
IES scale were used, one anchored to Hurricane Andrew as the stressful life event
and the other to HIV infection.
Life Orientation Test–Revised (LOT–R). We measured dispositional op-
timism with the LOT–R (Scheier, Carver, & Bridges, 1994), which consists of six
items, plus four filler items, tapping an individual’s generalized outcome expectan-
cies and their way of looking at life. The possible responses used in this study were
based on a 4-point Likert scale ranging from 1 (“I agree a lot”) to 4 (“I disagree a
lot”) and responses were scored so that high values reflected greater optimism. Al-
though the more commonly used scale is based on a 5-point Likert scale, this
4
1
-point scale has been used in other studies of dispositional optimism (Carver et al.,
993). The LOT–R has been shown to have a fairly high internal consistency of .78,
a test–retest reliability of .68 at 4 months, and good predictive validity.
Immunologic Measures
The immunologic measures in this study include T-helper/inducer (CD4+CD3+)
cell counts and IgG antibody titers to HSV–2, cytomegalovirus (CMV),
EBV–Viral Capsid Antigen (EBV–VCA), and Human Herpes Virus–Type 6
(HHV–6).
Lymphocyte phenotyping. Peripheral venous blood was collected between
the hours of 8:00 a.m. and 12:00 p.m. by a phlebotomist using sterile evacuated
tubes containing sodium heparin (Vacutainer, 6489, Becton–Dickinson,
Rutherford, NJ). Whole blood samples were used for cell phenotyping. A single la-
ser flow cytometer (EPICS C, Coulter Instruments Laboratories, Hialeah, FL) was
used with a whole blood, 3-color immunofluorescence procedure to determine the
distribution of lymphocytes. Specific pairs of fluorescence isothiocyanate,

166
CRUESS ET AL.
rhodomine, or energy coupled dye conjugated monoclonal antibodies were used to
determine lymphocyte distributions. A sample of 100 ul of whole blood was incu-
bated with the antibodies for 10 min at 23 °C after shaking. Erythrocytes were lysed
and washed using the Multi Q-Prep System from Coulter. Stained specimens were
run on the Epics Elite Analyser flow cytometer using the 488 nm laser line for quan-
tification of percentage positive cells by direct immunofluorescence. For
CD3+CD4+ cells, bit maps were set on the lymphocyte population of the forward
angle light scatter versus 90° light scatter histogram. Percentage positively stained
cells for each marker pair, as well as doubly stained cells, was determined using the
Prism software. The percentage values were converted to absolute counts by multi-
plying by the lymphocyte counts obtained from the MaxM hematology counter
(Coulter, Hialeah, FL).
Herpesvirus antibodies. Serum was separated and stored at –20 °C for anti-
body testing. IgG antibodies to CMV and EBV–VCA were measured using the
ELISA method (INCSTAR and Pharmacia reagents). IgG antibody titers to HSV–2
were assessed using the Clin-ELISA test kit and reagents supplied by INCSTAR
(Incstar, 1993, Kit 4510, 4512). Diluted serum samples were incubated with each
respective virus. If antibodies to the virus are present in the sample, antigen–anti-
body complexes (p–NPP for EBV and HSV, horseradish peroxidase and
Chromogen/Substrate tetramethylbenzisdine for CMV) formed and were then
bound to anti-human IgG. Samples were then allowed to react with a conjugate so-
lution, which resulted in color formation in the presence of virus-specific antibod-
ies. Absorbance was directly related to the amount of virus antibody present in the
serum. The IgG antibody titer to HHV–6 was measured using indirect
immunofluorescence. A 30-min incubation allowed for specific antibody to attach
to the antigen, after which samples were washed. Fluorescein-conjugated goat anti
human IgG was then added, and samples were washed and incubated again for 30
minbeforebeingviewedusingfluorescencemicroscopy. Antibodyvalueswerede-
termined by the highest dilution factor at which antibodies to HHV–6 are detect-
able. Values were then log 2 transformed to normalize the distribution. Only partic-
ipants with antibody titer values indicative of positive serostatus for a given
herpesvirus were used in each of the four sets of herpesviruses analyses run. Due to
differences in availability of sufficient sera and the inclusion of only participants
positive for each virus within the analyses for that virus, there were different num-
bers of cases for antibody tests as follows: 39 for EBV–VCA, 39 for CMV, 33 for
HSV–2, and 35 for HHV–6.
Nonspecific antibody levels. Total IgG levels were used to control for non-
specific polyclonal B cell activation. Rate nephelometry (ICS Analyzer II;
Beckman Instrument, Brea, CA) was used to assess IgG levels following a rate
kinetic method outlined by Fritsche and DeLeon (1975). Sera was diluted in a

OPTIMISM AND HIV AFTER HURRICANE ANDREW
167
dilutent buffer containing a nonionic detergent. Diluted samples were aliquoted
into a cuvette containing a polyethylene glycol (PEG) reactant buffer to increase re-
action rate and decrease complex solubility. Next, Mab to IgG was added and the
rate of complex formation was recorded. The antibody concentration was deter-
mined from the standard curve for each Mab using the maximum rate.
Control Variables
A number of behavioral and hurricane-related self-report variables were investi-
gated in this study as potential control variables between optimism and immune
measures due to their known immunomodulatory effects in other work
(Kiecolt-Glaser& Glaser, 1988). Those foundtohave a significant relationwiththe
immunologic dependent variables were controlled for in the main analyses. Alco-
hol and coffee consumption were both separately reported as the number of drinks
consumed in the past week. Mean number of hours of sleep per night during the past
week as well as total number of hours of exercise during the past week were also re-
ported by each participant. Number of days since the hurricane was calculated to
control for the potential effects of time and recovery. Hurricane-related damage
was assessed on a 4-point Likert scale ranging from 0 (no damage) to 3 (major dam-
age) for six areas: roofs, windows, automobiles, possessions, water damage, and
other damage not covered by these categories (Ironson et al., 1997). These scores
were then summed to yield a total damage score, ranging from 0 to 18. The degree
to which participants felt their life was threatened during the storm (life-threat) was
assessed on a 7-point Likert scale ranging from 1 (not at all) to 7 (absolutely) to
control for perceived danger and threat.
We also controlled for HIV-related stressor burden and the impact of social
support. HIV–IES total scores were used to control for HIV-specific psychological
distress. The number of months between HIV diagnosis and assessment, available
for 75% of the sample, was also investigated as a potential control variable for
those participants. Total number of HIV-related physical symptoms in the past
month was also used as a control variable. Social support was controlled for by ex-
amining intimate relationship status (coded dichotomously as yes vs. no), living
arrangements (coded as alone vs. with others), and availability of social support as
measured by the availability score of the Social Support Questionnaire (SSQ;
Sarason, Levine, Basham Sarason, 1983).
Procedure
Participants were assessed within 6 months of the landfall of Hurricane Andrew
(
2
August 24, 1992), beginning on October 1, 1992 and continuing through February
4, 1993. They were first assessed for anxiety and depression using the Structured
Interview Guide for Anxiety and Depression (SIGH–AD; Hamilton, 1959, 1960;

168
CRUESS ET AL.
Williams, 1988) and for mental status using the Mini Mental Status Exam (MMSE;
Folstein, Folstein, & McHugh, 1975). All potential participants were required to
meet specific cutoff scores on these instruments (> 25 on the MMSE and a depres-
sion rating < 15 on the SIGH–AD). The primary purpose of this screening was to
exclude individuals with any major cognitive impairments or major
psychopathology and create a relatively homogeneous sample of mentally healthy
individuals. All potential participants met the required cutoff scoresonthese instru-
ments and were then given a psychosocial questionnaire packet with instructions.
They were then scheduled for a second appointment 1 week later at which time they
returned their questionnaire, had their blood drawn, and were paid $25 for their par-
ticipation. To help control for possible confounding effects of physical illness on
immunological measures, participants reporting the experience of any acute physi-
cal illness (e.g., colds or flu) had their blood draw rescheduled for at least 1 week
following resolution of their symptoms.
RESULTS
Participant Characteristics
Participants in this study were 40 HIV seropositive gay men ranging in age from
2
1 to 57 (M = 37.2, SD = 7.9; see Table 1). The majority of participants were ei-
ther Hispanic or non-Hispanic White, and most had received at least some col-
lege education. At least half were earning over $20,000 per year, though income
3
was quite varied. Mean CD3+CD4+ number was 312.00/mm (SD = 194.7).
Based on self-report, approximately one half of the men were asymptomatic at
the time of entry into the study, with the other half mildly symptomatic. Only 1
participant was known to have had a previous diagnosis of AIDS, based on his
self-report of a past histoplasmosis diagnosis. Additionally, 4 men had a
3
3
CD3+CD4+ count below 100 cells/mm , 6 fell between 100 and 200 cells/mm ,
3
with the remainder having counts above 200 cells/mm . The average time of as-
sessment was 121.42 days after the storm (range = 28–189, SD = 62.35). When
asked to rate how much they felt their life was threatened during the storm, on a
scale from 1 to 7, 12.5% of participants indicated 7 (absolutely) and 17.5% re-
ported 1 (not at all). Many participants felt at least some moderate level of life
threat during the storm (M = 3.53, SD = 2.04).
Distress Levels After Hurricane Andrew
Means and standard deviations for distress measures are shown in Table 2. Psycho-
logical distress measures were compared with published normative data to examine
the relative distress levels of participants in this study. When compared with the
raw SCL–R–90 scores of 494 non-patient men comprising the SCL–90–R norma-

OPTIMISM AND HIV AFTER HURRICANE ANDREW
169
TABLE 1
Subject Characteristics
Characteristic
%
Ethnicity
Non-Hispanic White
Hispanic
African American
Haitian
45.0
37.5
2.5
2.5
Unknown or other
Education
12.5
Graduate degree
College graduate
Some college
Trade school
High school graduate
Less than eighth grade
Unknown
25.0
35.0
25.0
2.5
5.0
2.5
5.0
Income
Over $40,000
15.0
10.0
25.0
20.0
22.5
7.5
$
$
$
30,000–$40,000
20,001–$30,000
10,001–$20,000
Less than $10,000
Unknown
Living arrangements
Live with lover
Live alone
Live with parents
Live with roommate
Other or unknown
27.5
25.0
10.0
7.5
30.0
tive sample (Derogatis, 1983), participants in this study appeared to have higher
levels of SCL-depression and higher GSI scores (see Figure 1). Participants in this
study also appeared to have total IES scores (combining the avoidance and intru-
sion subscales) that were significantly higher than IES scores of male medical stu-
dents reacting to cadaver dissection (Horowitz, Wilner, & Alverez, 1979). We
compared participants’ IES, PTSD, and SCL–90–R scores to distress scores from a
community sample of 39 HIV– men, aged 20–57, who also experienced Hurricane
Andrew (see Figure 1). This sample of men was chosen from a random sample of 60
men in a community hurricane study to match as closely as possible in age and
mean damage scores (see Ironson et al., 1997, for a full description of the sample of
6
0 men). Separate analyses of covariance (ANCOVAs) controlling for time from
the storm until assessment and storm-related damage were conducted for each dis-
tress measure. All of the ANCOVAs were nonsignificant (ps > .10). These results
suggest that, in general, the participants in this study had mean levels of distress that

170
CRUESS ET AL.
TABLE 2
Descriptive Data For Psychological and Immunolologic Measures
HIV Hurricane Sample
Immune Comparison Sample
M
SD
M
SD
SCL–90–R
GSI
Depression
Anxiety
0.77
0.83
0.79
0.6
0.6
0.6
IES–Hurricane
Total
Intrusion
Avoidance
PTSD Scale
Total
14.38
7.74
6.66
15.1
7.3
9.7
18.11
7.37
7.23
14.3
7.4
5.1
Avoidance
Arousal
Intrusion
3.51
3.8
HHV–6 (log
HHV–6 (raw)
CMV
2
)
5.86
202.89
4.14
1.5
249.0
1.4
6.37
210.43
3.49
1.1
169.4
1.4
EBV–VCA
HSV–2
989.90
299.59
390.4
156.2
970.23
408.46
422.6
414.9
Note. SCL–90–R = Symptom Checklist–Revised; GSI = Global Severity Index; IES = Impact of
Events Scale; PTSD = posttraumatic stress disorder; HHV–6 = Human Herpes Virus–6; CMV =
cytomegalovirus; EBV–VCA = Epstein–Barr Virus–Viral Capsid Antigen; HSV–2 = Herpes Simplex
Virus–Type 2.
FIGURE 1 Comparison of SCL–90–R distress measures for HIV+ hurricane participants and
published norms.

OPTIMISM AND HIV AFTER HURRICANE ANDREW
171
were higher than normative samples and similar to a separate community sample of
HIV– men who also experienced Hurricane Andrew.
We hypothesized that optimistic attitudes would be associated with less psy-
chological distress in the months after the hurricane. This hypothesis was sup-
ported. Table 3 displays Pearson product–moment correlation coefficients
between optimism and distress measures. Optimism was significantly negatively
correlated with several distress indexes, including SCL–90–R GSI scores;
SCL–90–R depression and anxiety; and PTSD total, avoidance and arousal
scores, and was marginally associated with lower hurricane-specific IES avoid-
ance. These results suggest that, in general, men with greater optimism had less
hurricane-specific and general psychological distress in the months after the
storm.
Immune Status After Hurricane Andrew
Mean levels of antibodies against HSV–2 fell within the medium–positive range
(Incstar Herpes1 or 2 IgG Clinical ELISA Kit Instruction Manual, February,
1
995). Mean IgG values for EBV–VCA, CMV, and HHV–6 fell within the
1
strongly positive range and are similar to other samples of HIV-infected gay
men. See Table 2 for descriptive immunologic data. Because HSV–2 titers were
2
not elevated (in relation to laboratory norms), only EBV, CMV and HHV–6
titers were examined in subsequent analyses.
We hypothesized that optimism would be related to lower antibody titers to
these three herpesviruses. To control for the possibility that levels of virus-spe-
cific antibody titers were simply reflecting overall levels of circulating IgG anti-
body titers, we computed partial correlations between optimism and each
herpesvirus antibody titer, controlling for total IgG antibody level (see Table 4).
After controlling for total IgG, optimism was negatively correlated with HHV–6
and EBV titers, though not with CMV. One possible confound in the observed
relations between HHV–6 and EBV titers with optimism is health status: Health
status may be related to both optimism and antibody titer levels. We divided the
sample by a median split based on the men’s CD3+CD4+ cell count and com-
pared optimism and antibody titers between high and low cell count participants
via independent t tests. There were no significant differences between groups on
1Incstar VCA IgG or IgM Clin–ELISA Kit Instruction Manual, September, 1993; Clark Labora-
tories, Inc. CMV IgG ELISA Instructional Manual, January, 1995; Human Herpesvirus 6 Indirect Fluo-
rescent Antibody Test Package Insert, March, 1992.
2Comparison values for immunologic measures were taken from baseline measurements of a sample
of 100 HIV-infected gay and/or bisexual men participating in a stress management intervention study
(
(
Wagner, 1999). This comparison sample had a similar mean age (35.8 years), ethnic composition
55% White, 33% Hispanic), mean CD4 cell count (436.5 cells/mm ), and HIV symptom status (42%
3
asymptomatic) to this study sample.

172
CRUESS ET AL.
TABLE 3
Pearson Correlations Between Optimism and Psychological Distress Measures
Optimism
N
SCL–90–R
GSI
Depression
Anxiety
–.56***
–.56***
–.49**
29
29
29
IES–Hurricane
Total
Intrusion
Avoidance
PTSD Scale
Total
Avoidance
Hyperarousal
Intrusion
–.24
–.07
–.32*
29
29
29
–.51***
–.49***
–.51***
–.24
28
28
28
28
Note. SCL–90–R = Symptom Checklist–Revised; GSI = Global Severity Index; IES = Impact of
Events Scale; PTSD = posttraumatic stress disorder.
*
p < .10. **p < .05. ***p < .01.
TABLE 4
Partial Correlations Between Optimism and IgG Antibody Titers to Herpes Viruses
Virus
df
Controlling for IgG
Controlling for IgG and CD3 + CD4 + Number
HHV–6 (log
EBV–VCA
CMV
2
)
23
26
26
–.53***
–.33*
–.28
–.55***
–.32*
–.28
Note. HHV–6 = Human Herpes Virus–6; EBV–VCA = Epstein–Barr Virus–Viral Capsid Antigen;
CMV = cytomegalovirus.
*
p < .09. **p < .05. ***p < .01.
any of the variables examined (all ps > .05). We also ran partial correlations be-
tween optimism and the three herpesvirus antibody titers controlling for
CD3+CD4+ cell number, in addition to total IgG, which changed the original
partial correlations very little (see Table 4).
A data reduction strategy was used for the other variables investigated as poten-
tial confounds of the optimism–immune associations (availability of social support
and certain hurricane-related variables, HIV-related variables, and health behav-
iors). First, all control variables were independently correlated with the three
herpesviruses using Pearson’s product–moment correlation coefficients to deter-
mine which to examine as potential controls in regression analyses. For the viral an-
tibody titer measures, the only significant control–immune correlation was a
negative correlation between alcohol use and CMV IgG. After controlling for alco-

OPTIMISM AND HIV AFTER HURRICANE ANDREW
173
hol use in a hierarchical regression analysis, the association between optimism and
CMV IgG remained nonsignificant. Sleep, hours of exercise, coffee consumption,
time elapsed since the storm, and hurricane-related damage were not significantly
correlated with any herpesvirus antibody measure. Similarly, neither HIV-related
burden (measured by HIV symptom count, time since HIV diagnosis, and HIV IES
scores) nor availability of social support (as measured by relationship status, living
arrangements,andSSQscores)wasrelatedtoanyimmunologicoutcomemeasure.
Does Depression Mediate the Relation Between Optimism
and Immune Function?
We hypothesized that one mechanism through which optimistic appraisals are as-
sociated with immune functioning is by impacting levels of depression. We chose
depression to investigate as a mediator versus other measures of distress (e.g., anxi-
ety, PTSD symptoms) for several reasons. First, of our specific measures, depres-
sion was the strongest correlate of optimism. Additionally, previous work has sug-
gested a strong inverse association between depressed mood and optimistic
cognitive appraisals (Marshall & Lang, 1990; Scheier & Carver, 1992). Similarly,
pessimism, often considered the converse of optimism, also has a strong link to de-
pressive symptoms in the literature (Anderson, Spielman, & Bargh, 1992;
Hartlage, Arduino, & Alloy, 1998; Lewis, 1993; Maltby, Lewis, & Hill, 1998).
Therefore, we tested whether the observed relations between optimism and immu-
nologic measures were mediated by SCL depression. For a measure to be consid-
ered as a potential mediator variable, (a) the predictor variable (optimism) must be
significantly correlated with the criterion (antibody titer) and (b) the mediator must
be associated with both the predictor variable and with the criterion variable (Baron
&
Kenney, 1986). Evidence of mediation is demonstrated when the magnitude of
the association between the predictor and the criterion is substantially attenuated
when the contribution of the mediator is controlled in the prediction equation. The
measure of EBV antibody titers was the only immune measure significantly corre-
lated with the SCL–90–R depression scale (controlling for total IgG, partial r = .33,
p < .08). SCL depression was in turn correlated significantly with optimism as well
(r = –.56, p < .01). To test the hypothesis that the relation observed between opti-
mism and EBV titer was mediated by depression, mediation analyses were con-
ducted as outlined by Baron and Kenny (1986). EBV antibody titer, serving as the
criterion variable, was regressed first on the control variable (total IgG levels), and
then on the predictor (optimism) and the mediator (depression) variable, sepa-
rately. Depression scores were then regressed on optimism scores. In a final equa-
tion, depression scores were entered into the regression analysis in the first step,
followed by optimism in the second step to determine if the addition of depression
in the regression equation diminished the ability of optimism to predict EBV titers.
These analyses showed that depression appeared to partially mediate the relation

174
CRUESS ET AL.
FIGURE 2 Path analysis showing the relation between optimism and EBV–VCA IgG anti-
body titers once distress is controlled for. EBV–VCA values were first regressed on total IgG
levels. Numbers inside parentheses represent standardized Beta weights in the regression analy-
sis. *p < .09. **p < .05. ***p < .01.
between optimism and this immune measure such that higher optimism related to
lower EBV titers by way of the lower depression levels experienced by optimists
(see Figure 2).
DISCUSSION
The findings from this study indicate that optimism was significantly associated
with both psychological distress and immunologic control over several latent
herpesviruses among HIV-infected gay men in the months immediately after
Hurricane Andrew. Specifically, optimism was associated with lower levels of
depression, general distress, and hurricane-specific distress. After controlling for
nonspecific polyclonal B cell activation, greater optimism was also associated
with lower levels of circulating antibodies to HHV–6 and was marginally nega-
tively correlated with EBV IgG; these lower titers reflecting better control over
these viruses. Furthermore, results suggest that the association between optimism
and lower EBV titers was partially mediated by the lower depression levels ex-
perienced by optimists.
The levels of overall distress in this sample are similar to other samples of
symptomatic HIV+ men (Goodkin et al., 1992 Kurdek & Siesky, 1990). Clearly,
the men in this sample were experiencing a significant degree of psychological
distress, although the relative contribution of the stress associated with the hurri-

OPTIMISM AND HIV AFTER HURRICANE ANDREW
175
cane and that with HIV infection can not be fully discerned. However, it was
noteworthy that neither of the total scores measuring hurricane-specific distress
nor the total score measuring HIV-specific distress was significantly correlated
with any of the immunologic measures. Conversely, the SCL–90–R depression
scale, a measure of distress not specifically tied to environmental stimuli, was
positively associated with EBV antibody titers. Furthermore, neither hurri-
cane-specific control (burden) measures (time since the storm and hurricane-re-
lated damage) nor the HIV-specific control (burden) measures (time since HIV
diagnosis, number of HIV symptoms) were related to the immune outcomes
measured. This suggests that it may be the interaction of the men’s depressive
responses to the two stressors that may be most significant. Those individuals
strongly affected psychologically both by the chronic stress of HIV and the
acute stress of an environmental event may be most at risk for concomitant im-
munologic disruption. However, without pre-storm measurements of depression
we are unable to determine precisely the relative significance of each stressor.
Post hoc correlations between the SCL–90–R depression scale on the one hand
and the HIV–IES total score (r = .58, p < .01) and the hurricane-IES total score
(r = .34, p < .07) on the other suggest that HIV-specific intrusion and avoidance
may be more strongly related to ongoing depressive symptoms. Future research
is needed to more clearly elucidate the relative importance of the various acute
and chronic stressors that HIV individuals must face in predicting their overall
psychological well being as well as their immunologic status.
Surprisingly, there were no significant elevations in HSV–2 titers in the months
after Hurricane Andrew. The absence of Significant Distress × HSV titer associa-
tions in the present work is inconsistent with Robertson et al.’s (1993) data relating
greater distress and higher HSV titers in an HIV+ sample. Many other studies have
shown significant associations of distress responses with HSV titers and symptom
recurrences in healthy populations (Glaser & Kiecolt-Glaser, 1997; Kemeny, Co-
hen, Zegans, & Conant, 1989; Kiecolt-Glaser et al., 1985; Silver, Auerback,
Vishniavsky, & Kaplowitz, 1986) as well as HIV-infected gay men (Lutgendorf et
al., 1997). The lack of consistency between our HSV findings and theirs remains
unclear.
On the other hand, antibody titers to the herpesviruses EBV, HHV–6, and CMV
observed in this sample were elevated compared to laboratory norms. In the case
of EBV and HHV–6, these values were notably higher than those previously ob-
served among HIV+ gay men dealing with other stressors such as the initial notifi-
cation of HIV seropositivity (Esterling et al., 1992). Although it is unlikely that a
catastrophic natural disaster will be a common occurrence for any individual, the
acute fear and distress associated with such an event and the subsequent losses and
chronic stress during recovery and rebuilding may be somewhat comparable in
magnitude to the multiple acute and chronic stressors that HIV+ individuals are
continually faced with (e.g., health care access difficulties, stigmatization, and

176
CRUESS ET AL.
multiple bereavements). This study allows us to gain a better understanding of the
relations between psychological and physiological stress responses in HIV-in-
fected individuals under high levels of environmental stress. Other studies of clini-
cal populations exposed to natural disasters suggest that increases in
disease-related symptoms may be influenced during the stressful aftermath of
these events. Exacerbation of physical symptoms was documented in populations
of patients with two different immune-related conditions (CFS and RA) following
the occurrence of major hurricanes (Grady et al., 1991; Lutgendorf et al., 1995).
Both CFS and RA patients are believed to be suffering from a condition in which
excessive humoral immune activity (i.e., dominance of TH2-lymphocyte function)
in combination (in the case of CFS) with impaired cell-mediated immunity (i.e.,
subordinate role of TH1-lymphocyte function) often occurs in addition to the clini-
cal symptoms defining these syndromes or diseases. Because HIV infection in
adults is hypothesized to reveal a successive shift from TH1 to TH2 dominance as
the disease progresses to clinical manifestations, it is plausible to speculate that
stressor-associated impairments in TH1-like functions (cell-mediated immunity)
might favor both impairments in surveillance of latent viruses and HIV disease
progression (Clerici & Shearer, 1994).
Optimism, Distress, and Immunologic Status
As hypothesized, optimism was significantly associated with less psychological
distress in the months following the hurricane. Optimism was also significantly re-
lated to antibody titers to HHV–6 and marginally to EBV titers. Optimists appeared
to have lower antibody titers, suggesting better cellular control over these viruses
(
Antoni et al., 1995; Esterling, Antoni, Kumar, & Schneiderman, 1993; Glaser &
Kiecolt-Glaser, 1987). These findings are consistent with those of Esterling et al.
1992),whereEBVantibodytitersweredecreasedinHIV+gaymenwhocompleted
(
a Cognitive Behavioral Stress Management (CBSM) intervention. This interven-
tion has been shown to reduce distress and depressive symptoms (Lutgendorf et al.,
1
997) and appears to do so, in part, by increasing the use of cognitive coping strate-
gies such as positive reframing and acceptance (Lutgendorf et al., 1998). This sug-
geststhat, forthisstudy, optimisticstressorappraisalsmightbemaintainedbyflexi-
ble cognitive coping strategies that help to lower depressive symptoms, which in
turn predict better immunologic control of herpesviruses such as EBV. Another
mechanism by which optimistic appraisals may exert their effects, not mutually ex-
clusive to the first pathway suggested, is by maintaining active coping efforts. Re-
centempiricalworkhasprovidedstrongevidenceforthepossibilitythatoptimism’s
effectondistressmaybeatleastpartiallymediatedbyincreasingactivecopingorat-
tenuating avoidance coping (Carver et al., 1993; Friedman et al., 1992; Scheier,
Weintraub, & Carver, 1986; Segerstrom et al., 1998).

OPTIMISM AND HIV AFTER HURRICANE ANDREW
177
Indeed, we found support for the hypothesis that optimism’s relation with lev-
els of EBV antibody titers is at least partially mediated by depression. These find-
ings provide partial support for a psychoneuro immunologic model of stress
responses in which appraisals are thought to influence depression levels, which in
turn may influence immune function. The mechanisms tying optimism to physio-
logical changes and better health outcomes may involve its ability to mitigate the
effects of overwhelming stressors on future outlook and depressive symptoms.
Such a process would seem to be especially salient in the case of a natural disaster
such as a hurricane, which is characterized by extreme losses. We reasoned that
studying this process in HIV-infected persons in the wake of Hurricane Andrew
was relevant given the compounded sense of loss many of these men were likely to
experience and the heightened risk for their developing depressive symptoms in
the months that followed the storm. It is entirely possible that very optimistic
men were able to deal with their losses in such a way that they became less de-
pressed, which in turn minimized any perturbations in cellular immune processes
controlling latent viruses such as EBV. A large number of studies have docu-
mented associations between depressive symptoms and many immune measures
including EBV (see Herbert & Cohen, 1993, for review). However, given that our
findings are cross-sectional, the direction of the relationships cannot be stated
conclusively. It is possible that herpes virus activation/re-activation due to HIV
viral activity or stressors could contribute to depressive symptoms via elevations in
pro-inflammatory cytokines (Connor & Leonard, 1998).
The implications of these immunologic findings, as mentioned previously, may
be particularly significant for HIV+ individuals in light of the possible activation
of HIV from stress-related reactivation of those herpesviruses studied herein
(Antoni et al., 1995; Kucera et al., 1990; Lusso et al., 1990). Glaser and
Kiecolt-Glaser (1987) hypothesized that as stress may lead to reactivation of latent
herpesviruses, this reactivation may help down-regulate the cellular immune re-
sponses controlling virus genomes, including HIV. Rosenburg and Fauci (1989)
also noted that long-term non-HIV-producing T cells can be stimulated (by plant
mitogens) to produce HIV and that chronically HIV-infected cells can increase
their production of HIV as well when stimulated. This highlights the question of
whether chronic reactivation of latent herpesviruses in HIV+ individuals can cause
enough stimulation of the immune system to induce chronically or latently in-
fected cells to produce HIV more actively.
One of the primary limitations of this study is its relatively small sample size of
4
0 men. With a sample of this size, questions of generalizability arise. Unfortu-
nately, the sample represents a self-selected group of men that may not be compa-
rable to other individuals living with HIV. Furthermore, similar data were not
available to test the hypotheses in women or in a sample of HIV– men who under-
went Hurricane Andrew, thus the specificity of the findings to men or individuals
with HIV+ or other chronic illnesses cannot be stated. There is also the possibility

178
CRUESS ET AL.
that, due to limited statistical power, significant associations were not detected due
to Type II error. Alternatively, associations derived from samples of this size may
be spurious due to the heightened impact that individual cases can have on the cor-
relation coefficient; hence Type I error is a risk as well. In addition, there were no
prehurricane levels of distress or antibody titers available for participants, thus
temporal associations between psychosocial factors and immune changes could
not be ascertained. Similarly, although levels of HIV specific distress were mea-
sured and controlled for, it cannot be said how much of the general distress mea-
sured in this study was reflective of Hurricane Andrew versus other stressors.
Despite these limitations however, our findings do suggest that optimists may ex-
perience fewer depressive reactions accompanying acute and prolonged environ-
mental stressors, especially those characterized by losses. Optimism may also help
to attenuate stress-associated increases in EBV antibody titers. Consistent with
previous research, optimism seems to exert its effect on these antibody titers via its
association with lower depression levels in the face of stressors.
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